metadata: authors: 0: author: Briceno,Bertha
1: author: Coville,Aidan
2: author: Martinez,Sebastian
count: Tanzania
docna: 0: docna: Promoting handwashing and sanitation :
            evidence from a large-scale randomized trial in rural Tanzania
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Sanitation and Sewerage,Engineering,Demographics,Water and Human Health,Hydrology,Water Supply and Sanitation Economics,Sanitary Environmental Engineering,Small Private Water Supply Providers,Environmental Engineering,Health and Sanitation,Town Water Supply and Sanitation
abstracts: cdata!: The association between hygiene,
            sanitation, and health is well documented, yet thousands of
            children die each year from exposure to contaminated fecal
            matter. At the same time, evidence on the effectiveness of
            at-scale behavior change interventions to improve sanitation
            and hygiene practices is limited.  This paper presents the
            results of two large-scale, government-led handwashing and
            sanitation promotion campaigns in rural Tanzania. For the
            campaign, 181 wards were randomly assigned to receive
            sanitation promotion, handwashing promotion, both
            interventions together, or neither. One year after the end
            of the program, sanitation wards increased latrine
            construction rates from 38.6 to 51 percent and reduced
            regular open defecation from 23.1 to 11.1 percent.
            Households in handwashing wards show marginal improvements
            in handwashing behavior related to food preparation, but not
            at other critical junctures. Limited interaction is observed
            between handwashing and sanitation on intermediate outcomes:
            wards that received both handwashing and sanitation
            promotion are less likely to have feces visible around their
            latrine and more likely to have a handwashing station close
            to their latrine facility relative to individual treatment
            groups. Final health effects on child health measured
            through diarrhea, anemia, stunting, and wasting are absent
            in the single-intervention groups. The combined-treatment
            group produces statistically detectable, but biologically
            insignificant and inconsistent, health impacts. The results
            highlight the importance of focusing on intermediate
            outcomes of take-up and behavior change as a critical first
            step in large-scale programs before realizing the changes in
            health that sanitation and hygiene interventions aim to deliver.
geo_reg_key: 517191
repnme: repnme: Promoting handwashing and sanitation :
            evidence from a large-scale randomized trial in rural Tanzania
display_title: Promoting handwashing and sanitation
            : evidence from a large-scale randomized trial in rural Tanzania
listing_relative_url: /research/2015/01/23804984/promoting-handwashing-sanitation-evidence-large-scale-randomized-trial-rural-tanzania
topicv3: Sanitation m1326453 2000,Water m1326522 137,Health m1504661 3480,Latrines m1505177 3454,Sanitation Marketing m1505179 3456
publishtoextweb_dt: 2015-01-01T00:00:00Z
no_of_pages: 60
author_keys: 0: author_key: 1069786
1: author_key: 1063728
2: author_key: 762965
model_extractions: WPS7164 Policy Research Working Paper 7164

# Promoting Handwashing and Sanitation

Evidence from a Large-Scale Randomized Trial in Rural Tanzania _Bertha Briceño Aidan Coville Sebastian Martinez_ Water Global Practice Group & Development Research Group Impact Evaluation Team January 2015
Policy Research Working Paper 7164

# **Abstract**

The association between hygiene, sanitation, and health is well documented, yet thousands of children die each year from exposure to contaminated fecal matter. At the same time, evidence on the effectiveness of at-scale behavior change interventions to improve sanitation and hygiene practices is limited. This paper presents the results of two large-scale, government-led handwashing and sanitation promotion campaigns in rural Tanzania. For the campaign, 181 wards were randomly assigned to receive sanitation promotion, handwashing promotion, both interventions together, or neither. One year after the end of the program, sanitation wards increased latrine construction rates from 38.6 to 51 percent and reduced regular open defecation from 23.1 to 11.1 percent. Households in handwashing wards show marginal improvements in handwashing behavior related to food preparation, but not at other critical

- junctures. Limited interaction is observed between hand washing and sanitation on intermediate outcomes: wards that received both handwashing and sanitation promotion are less likely to have feces visible around their latrine and more likely to have a handwashing station close to their latrine facility relative to individual treatment groups. Final health effects on child health measured through diarrhea, anemia, stunting, and wasting are absent in the single-intervention groups. The combined-treatment group - produces statistically detectable, but biologically insignifi cant and inconsistent, health impacts. The results highlight the importance of focusing on intermediate outcomes of take-up and behavior change as a critical first step in large-scale programs before realizing the changes in health that sanitation and hygiene interventions aim to deliver.

This paper is a product of the Water Global Practice Group and the Impact Evaluation Team, Development Research Group. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http:// econ.worldbank.org. The authors may be contacted at acoville@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# **Promoting Handwashing and Sanitation: Evidence from a Large-Scale Randomized Trial in Rural Tanzania**

Bertha Briceño Aidan Coville Sebastian Martinez<sup>1</sup> Keywords: Handwashing, sanitation, behavior change, health, Tanzania, field experiment JEL codes: O12, I15, C93

> 1 _Briceño_ : Inter American Development Bank, 1300 New York Avenue, NW, Washington DC 20577, berthab@iadb.org; _Coville_ : World Bank, 1818 H St NW, Washington DC 20433, acoville@worldbank.org; _Martinez_ : Inter American Development Bank, 1300 New York Avenue, NW, Washington DC 20577, smartinez@iadb.org.
# **Acknowledgements**

Kaposo Mwambuli, Water and Sanitation Specialist, and Yolande Coombes, Senior Water and Sanitation Specialist from WSP are gratefully acknowledged as being part of the evaluation team and providing continued support and comments throughout the project during design, implementation, and analysis.

We thank the Ministry of Health and Social Welfare and Preventive Health Department in Tanzania, especially Dr. Khalid Massa, Elias B.M. Chinamo and Anyitike P. Mwakitalima. Professor Paul Gertler has provided guidance and advice throughout the project. Advisors also include Sebastian Galiani, John Colford, Benjamin Arnold, Pavani Ram, Lia Fernald, and Patricia Kariger.

The authors are also grateful to the former and current regional team leaders for WSP-Africa, Wambui Gichuri and Glenn Pearce-Oroz; Eduardo Perez, the global task team leader for the Scaling Up Rural Sanitation program; and Claire Chase, WSP Economist. We are also grateful to Jacqueline Devine, Senior Water and Sanitation Specialist, for helpful comments on this paper.

The WSP-Tanzania country technical assistance team was led by Nathaniel Paynter, followed by Jason Cardosi and now C. Ajith Kumar, with continued and extensive support from Kaposo Mwambuli and Patrick Mwakilama. Endline data collection was conducted by EDI Africa.

Nicolas Ajzenman provided skillful research assistance. Alicia Salvatore oversaw the in-country design and field activities in the early stages of the project. Martinez’s work on this project between 2007 and 2010 was conducted as an economist at the World Bank. Briceño’s work on this project between 2010 and 2014 was conducted as a Senior Monitoring and Evaluation Specialist at WSP.

Generous financial support was provided by the Bill & Melinda Gates Foundation.

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# 1. **Introduction**

Understanding how to reduce enteric and diarrheal diseases has important implications for child morbidity, mortality and long-term growth. Diarrhea is the second largest killer of children under five (WHO-UNICEF, 2013), and poor nutrition at an early age can cause growth faltering and reduced cognitive development in the longer term (Victora _et al._ , 2008). Exposure to, and ingestion of, contaminated fecal matter is understood to be the main pathway through which children are exposed to diarrheal diseases and other afflictions that affect nutrient absorption and longer-term growth, such as soil-transmitted helminthes and environmental enteropathy (Humphrey, 2009). Poor children in developing countries are the ones most at risk of exposure.

Given their role in reducing fecal-oral pathogen transmission, hygiene and sanitation programs are often cited as important development interventions to reduce morbidity and mortality worldwide. It is estimated that unsafe water, and inadequate sanitation and hygiene contribute to over one million deaths per year, or 1.5% of all deaths (Prüss-Ustün _et al_ , 2014); in Sub-Saharan Africa, these deaths are mostly of children under 5 years old. As a result, governments and the international community are increasingly investing in the provision of water, sanitation, and hygiene (WASH) for the poor. However, the existing evidence on the effectiveness of these investments when delivered at scale is limited and of varied quality.<sup>2</sup> Small-scale efficacy trials show large reductions in diarrhea from handwashing interventions (Ejimot-Nwadiaro _et al._ , 2008), but there are important concerns about potential measurement bias of self-reported measures (Schmidt, 2014). Apart from recent promising work in India (Biran _et al._ , 2014), most of the available research suggests that, when taken to scale, sustained behavior change remains elusive (Chase & Do, 2012; Galiani _et al._ , 2012). Currently, we do not have efficacy trials of sanitation on which to provide a benchmark, and the little evidence on effectiveness trials of rural sanitation interventions is far from conclusive.<sup>3</sup> There are a number of reasons identified in the literature that explain why we may see no, or even negative, impacts on health from sanitation interventions. Improved latrine coverage may do little to reduce exposure to other important contaminants such as animal feces (Ngure _et al._ , 2013). Due to the externalities associated with open defecation, health improvements may not be observed if there is limited take-up in the community (Andres _et al._ , 2013). Increasing latrine coverage may even have unintended negative consequences, by contaminating groundwater through seepage (Dzwairo _et al._ , 2006) or increasing exposure to feces through unhygienic facilities (Greene _et al.,_ 2012). The latter points towards potentially important complementarities between sanitation and hygiene campaigns. While the importance of exposure to contaminated fecal matter on the burden of disease is not in dispute, the effectiveness of hygiene and sanitation promotion campaigns to

> 2 See Clasen _et al_ . (2010), Fewtrell _et al_ . (2005), Kremer and Zwane (2007), Independent Evaluation Group (2008), Waddington _et al_ . (2009), Cairncross _et al_ . (2010), and DFID (2011).

> 3 See Cameron et. Al (2013), Patil _et al_ (2014), Clasen _et al._ (2014) and Hammer & Spears (2013).

3
adequately reduce this transmission mechanism, particularly when implementing large-scale programs, is still an open and important empirical question.

We evaluate the impact of two large-scale, government-implemented programs that promote handwashing with soap and improved sanitation in rural Tanzania. The programs are part of a multi-country effort to address poor hygiene and sanitation conditions for large rural populations in the developing world, implemented through local governments with assistance from the World Bank.<sup>4</sup> From mid-2009 to early 2011, the two interventions were rolled out in 10 districts<sup>5</sup> of Tanzania following a factorial experimental design. 181 rural wards included in the study were divided into 4 groups to receive the handwashing intervention alone, the sanitation intervention alone, both the handwashing and sanitation, or neither intervention (control). We conducted an endline survey in 2012, approximately one year after the conclusion of the program. The survey includes 3,619 households and 5,768 children under five, with an effective response rate of 97.8%. The trial was registered as NCT01465204 at clinicaltrial.gov.<sup>6</sup> Handwashing wards were provided with a package of intensive social marketing interventions, including training of community activists, direct consumer contact through road shows, mass media campaigns and promotional activities, and technical assistance to build handwashing stations with local materials. Sanitation wards received a similar package of marketing efforts coupled with a community-led total sanitation triggering event geared towards increasing demand for improved sanitation facilities and promoting open defecation free (ODF) communities, followed by the creation of a village sanitation committee in charge of ensuring sustained behavior change. This was complemented with supply side interventions to train local masons in latrine construction and marketing. In both cases, sanitation marketing messages concentrated on positive aspirational messages rather than shame tactics. No subsidies were used.

Approximately one year after the end of the program, treatment households are significantly more likely to report being exposed to handwashing and sanitation messages of the sort used by the program. Households in sanitation wards are more likely to know of a mason who builds latrines and be aware of a sanitation committee operating in their village. Private latrine construction increased by 12.4 percentage points over the intervention period, a relative increase of 33% compared to the control. Increased latrine coverage leads to a 52% decline (23.1% vs 11.1%) in reported open defecation as the primary means of depositing feces in sanitation wards. Handwashing results are less impressive. Households in handwashing wards show marginal improvements in handwashing with soap prior to food preparation but not at other critical

> 4 Since 2007, the Water and Sanitation Program (WSP) has provided technical assistance to local and national governments implementing large rural sanitation and handwashing promotion programs in India, Indonesia, Peru, Senegal, Tanzania, and Vietnam, under the umbrella of two related projects, Global Scaling Up Handwashing and Global Scaling Up Rural Sanitation. More information is available at www.wsp.org/scalingupsanitation.

> 5 Out of 129 districts in Tanzania at the time of the 2002 census. These districts cover a population of 2,7 million people. 6 http://clinicaltrials.gov/ct2/show/NCT01465204

4
junctures such as after defecation. We also find small but significant improvements from handwashing promotion along other indicators of cleanliness including the child’s state of cleanliness, caregiver’s hands, probability of covering food and cleaning of the household latrine. Intermediate outcomes in the combined handwashing and sanitation intervention are consistent with impacts found in the single intervention wards. We find no clear evidence of meaningful health impacts. On the one hand, using 34,045 child observations from the listing data, we find a marginally significant (12.5%) reduction in diarrhea,<sup>7</sup> particularly for children under three in the combined treatment wards, pointing towards potential complementarities. The household survey data of 5,768 children shows a statistically insignificant reduction. Counterintuitively, we also find small but significant reductions in hemoglobin levels measuring iron-deficiency anemia (1.5%) and weight-for-age in the combination ward, which could be driven by gut infections and soil-transmitted helminthes (STHs) reducing the body’s ability to absorb nutrients. These anemia and weight results are statistically significant but biologically small. We show that this counterintuitive result is unlikely to be driven by selective mortality or poor quality latrine construction and the results remain robust to a number of different specifications.

The study design presents some limitations which we mention upfront. First, the 10 districts where we conduct the study were selected by government based on political priority rather than random selection, affecting the external validity of the study. This said, comparing our control group to representative surveys of rural Tanzania, including the 2010 Demographic and Health Survey and National Panel Survey, reveals that the two areas are more similar than not along basic observable characteristics (refer to Table 1). Since these are predominantly rural households, we also find that our sample is poorer on average than the national population. Following Filmer and Pritchett (2001), we use principal-components analysis to derive a wealth index based on 16 household assets captured both in the study questionnaire and the nationally representative 2010-2011 Living Standards Measurement Survey (LSMS). By plotting the wealth distributions of the impact evaluation and LSMS samples, Figure 1 shows that approximately 57% of the impact evaluation group falls below the 40<sup>th</sup> percentile of the national wealth distribution – the target group for the World Bank’s goal of increasing shared prosperity.

The second important concern is that we lack a baseline of pre-intervention characteristics.<sup>8</sup> While we attempt to reconstruct baselines for key variables, these suffer from problems of recall. Differential migration and attrition could also be a concern. However, data from the complete census listings of selected enumerator areas provides evidence of limited migration and attrition. Less than 5% of households moved into the community within the three year intervention period,

> 7 The household-level indicator for diarrhea including 5768 households does not find any significant effect on diarrhea, although the direction of the sign for the coefficient is consistent.

> 8 Although a baseline data collection was intended, unanticipated problems with reliability of data resulted in the cancelation of field work in five out of the 10 districts originally planned and the impossibility of using the data to validate the randomized design, as it was originally planned.

5
and this does not differ across treatment groups. We mitigate any confounding that migration may cause by restricting the sample to households residing in the area since 2009. Finally, though this study represents one of the first attempts to experimentally test the impact of handwashing and sanitation interventions separately, the study design does not isolate the impact of multiple individual components that make up each of the handwashing and sanitation intervention packages.

Our study complements the literature by providing the first experimental evidence of the separate and combined effects of sanitation and hygiene campaigns at scale. The work adds to the growing body of evidence suggesting that, while handwashing with soap may be an effective way to reduce an important fecal-oral transmission mechanism, getting people to actually change their behavior is incredibly difficult (Chase & Do, 2012). The work contributes to a more limited literature on the causal effects of rural sanitation. Companion studies in Indonesia and India have shown that, while it is possible to increase latrine construction through similar promotion campaigns,<sup>9</sup> these changes fall short of ensuring universal latrine coverage, limiting the potential for positive health outcomes (Cameron _et al.,_ 2013; Patil _et al._ , 2014).<sup>10</sup> More recent work by Clasen _et al._ (2014) finds a similar conclusion even with relatively large improvements in latrine coverage (52 percentage point increase). The results highlight the importance of first addressing take up and behavior change as a central goal of at-scale WASH interventions before embarking on the quest for health impacts (Coville & Orozco, 2014).

The paper is presented in the following way: Section 2 describes the causal chain linking sanitation and handwashing to improved health (presented visually in Figure 2), contextualizes the problem in Tanzania, and describes the program interventions and implementation in detail. Section 3 describes the study design, Section 4 provides an overview of the data and Section 5 outlines the econometric specification used to derive the results. Section 6 presents results, followed by robustness checks in Section 7. We discuss some possible mechanisms to explain the counterintuitive health outcomes in Section 8 and conclude in Section 9.

# **2. Handwashing and Sanitation Promotion** **_2.1._** _Transmission Mechanism_

Better sanitation, through safe containment of human feces and reductions in open defecation, is expected to decrease the presence of fecal pathogens in the environment, which can otherwise be transmitted via soil, surface water, hands or flies. Similarly, handwashing at critical times can decrease the risk of infection by reducing the presence of enteric pathogens in the hands/fingers

> 9 An important difference in India’s Total Sanitation Campaign is that latrine promotion is accompanied by a subsidy which is not the case in Indonesia or Tanzania.

> 10 Hammer & Spears (2013) find a large improvement of India’s Total Sanitation Campaign on child stunting, and while the analysis is rigorous, the results are somewhat implausible from a biological viewpoint given the small changes in latrine construction, which suggests possible data quality concerns.

6
and objects or utensils of frequent use, thus reducing the chances of person-to-person transmission and food or water contamination. The variety of transmission channels has been summarized in the seminal “F-diagram” reproduced in Figure 3.

High levels of enteric pathogens manifest in three main ways that adversely affect nutritional outcomes, especially for young children: diarrheal diseases, gastrointestinal infections and intestinal parasitic infections (soil helminthes and protozoans).<sup>11</sup> The pathogens that cause diarrheal diseases are transmitted mainly via fecal-oral routes, by ingestion of contaminated food, water, or other beverages, by direct or indirect contact with contaminated hands, animal or human feces.<sup>12</sup> Gastrointestinal infections and environmental enteropathy, are caused by ingestion of fecal bacteria in large quantities. Intestinal parasitic infections such as ascariasis, trichuriasis and hookworm are transmitted through soil contaminated with feces; giardia is a waterborne infection but can also be transmitted through food and person-to-person contact.

Despite being less visible than diarrheal diseases, subclinical gastrointestinal infections and intestinal parasitic infections also affect nutrition in substantial ways. The absorption of nutrients is reduced by direct loss through diarrhea, especially by repeated episodes, but also by continuous and silent theft of nutrients by parasites (including blood by hookworm), and by diversion of energy and proteins to combat infections.<sup>13</sup> Environmental enteropathy reduces absorptive capacity while increasing permeability of the small intestine (Humphrey, 2009). The result is faltering weight and height for age and increased risk of anemia.<sup>14</sup> It is commonly believed, on the basis of practitioners’ claims and some observational studies, that water, sanitation and hygiene investments may result in additional benefits when provided together. Arnold _et al._ (2013) note that, even though some observational studies and theoretical modeling of transmission pathways support the use of combined approaches promoted by implementing agencies, rigorous evidence justifying this approach is scarce. A meta-analysis by Fewtrell _et al_ . (2005) finds that the only evidence on combined interventions do not reduce diarrhea more than individual interventions. Our study, being the first large randomized trial exploring gains from sanitation promotion and handwashing implemented separately and in combination, provides important evidence for understanding the potential complementarities of WASH provision for at-scale interventions.<sup>15</sup>

> 11 Other important tropical diseases that can be prevented through adequate water, sanitation and hygiene include trachoma and schistosomiasis.  [Mara, 2010]

> 12 See Clasen _et al_ . (2010), Prüss _et al_ . (2008)

> 13 Chambers ,R (2012) Handout on fecally-transmitted infectious and undernutrition.

> 14 Helminth infections are also frequent cause of anemia in pregnant women [Mara, 2010]

> 15 In the near future, it is expected that other ongoing trials like the WASH benefits study will contribute to a more comprehensive understanding of the interactions among water quality, sanitation, handwashing, and nutrition interventions alone and combined designed as an efficacy trial for proof of concept.  See Arnold _et. al_ (2013) for the complete study protocol.

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This study measures the effects of the sanitation and handwashing interventions on the health of children under five years old. These children represent the age group most susceptible to diarrheal disease, growth faltering and acute lower respiratory infections, which are major causes of childhood morbidity and mortality in developing countries.

# **_2.2._** _Context: Rural Tanzania_

Approximately 70% of Tanzania’s population lives in rural areas characterized by subsistence livelihoods, poor access to health and education services, and high morbidity and mortality rates. The 2010 Demographic and Health Survey estimated that 9.2% of children in rural Tanzania died before their fifth birthday, 13.6% experienced diarrhea within a 2 week period, and 57.8% could be classified as anemic. Stunting and wasting, as measured by height-for-age and weightfor-age z-scores, is also commonplace, with 44.5% of children under 5 falling below two standard deviations of the reference population mean in height-for-age measures and 4.9% for weight-for-age measures. Less than half of the rural population has access to an improved water source, and more than half spends over 30 minutes collecting water. The country experienced a rapid acceleration of sanitation coverage following a cholera outbreak in the late 1970s, with widespread adoption of basic latrines in rural areas. Coverage in rural areas was estimated at 50 percent by 1980 and the 93/94 HRDS<sup>16</sup> survey found that 92.3% of rural Tanzanian households had a traditional or improved pit latrine. Over time, these (mostly shared) facilities gradually fell into disrepair and, currently, do not meet the JMP standards for “improved” sanitation (World Bank, 1996). As such, while most Tanzanian households have access to some form of latrine, the majority of these latrines can be more accurately described as ‘fixed-point open defecation’. While approximately 80% of households have access to a pit latrine, only 8% have a slab to ensure that fecal matter is safely separated from human contact. Open defecation continues to be the most common form of toileting among 18% of households and child feces are disposed of in an unsafe manner 40% of the time.

The 92 villages in 46 wards included as our study control sample provide a nuanced snapshot of sanitation and hygiene conditions in our study area absent the intervention.<sup>17</sup> While 80% of households have a pit latrine with slab or VIP latrine, more than 40% of these slabs are in disrepair and a third of the facilities are shared with other households. Furthermore, only 17% of these latrines have a cover for the squat hole to contain the feces and reduce potential transmission by flies, and more than two-thirds of the households with squat hole covers did not have them in place when visited. Our data show that, although people are aware of the

> 16 Tanzania Human Resources Development Survey, 1993/94 17

> Note that control areas were exposed to mass media campaigns on the radio.

8
importance of washing hands with soap, the presence of soap and handwashing devices,<sup>18</sup> together with actual handwashing behavior, remains low. We observe that 82% of caregivers know that handwashing with soap and water is the best method for cleaning hands, while only 8% of households have any soap visible near the place where hands are washed and only 1.2% have a fixed handwashing device. In-depth structured observations reveal that any form of handwashing at critical junctures, such as post-toileting or before eating, is low (27%), and washing hands with soap is substantially lower (4%). Households have toileting facilities, but they are in disrepair and often lack the ability to effectively store fecal matter safely and reduce the risk of contamination. Caregivers have basic knowledge of appropriate handwashing behavior, but fail to translate this into practice.

# **_2.3._** _Rural Sanitation: Total Sanitation and Sanitation Marketing_

The rural sanitation intervention – Total Sanitation and Sanitation Marketing (TSSM) – combines demand- and supply-side strengthening in an attempt to shift the sanitation equilibrium in targeted villages. TSSM uses Community Led Total Sanitation (CLTS) and sanitation marketing to increase demand for improved sanitation, while strengthening the supply of sanitation goods and services to local markets, with the aim of making these products more affordable and accessible. The objective of the program is to move all household members up the sanitation ladder, away from open defecation and towards the use of improved latrines, thereby creating ODF communities.

CLTS is an approach originally championed in South Asia to reduce open defecation by using community mobilization activities and behavior change strategies. CLTS recognizes that poor sanitation practices pose a fundamental collective action problem and uses a catalytic “triggering” event to highlight the problems created by open defecation. A CLTS leader triggers a community by bringing community members together and producing a defecation map, highlighting all of the areas where defecation occurs. Community members then visit these locations on a transect walk. Finally, the facilitator conducts a feces calculation to highlight the quantity of fecal matter produced in the community, and generates a mobility chart to show households how the fecal matter inevitably contaminates drinking water. In Tanzania, the CLTS model deviated from its usual focus on a shame-triggered message that urges behavior change, to a more positive one focusing on aspirations and pride (Perez _et al._ , 2012). The project trained local CLTS trainers at the district level who, in turn, trained CLTS facilitators in each ward. Facilitators then performed CLTS triggering in the communities, after which communities would create a CLTS committee consisting of 5 members who would be responsible for starting a

> 18 Most handwashing devices in our sample are simple mobile buckets with water and soap.  We differentiate between mobile devices such as these and more permanent “fixed” devices which include tippy taps (specifically promoted by the intervention), a sink with tap or fixed basin.

9
village latrine register and monitoring progress, while continually motivating households to move up the sanitation ladder.

CLTS activities were accompanied by intensive sanitation marketing and promotion campaigns directed towards the head of the household. Marketing approaches included direct consumer contact (DCC) which are large, community-based events, and mass media (print and radio). Promotional activities at the village level were delivered by village leaders, community health workers, as well as the CLTS champions. To maintain focus on aspirations, activities of the sanitation marketing campaign fell under the common slogan _Choo bora chawesekana_ (“a good latrine is possible”).

While the mass media radio campaign was broadcasted across the country, 182 villages in 91 wards were targeted to receive direct sanitation marketing efforts through promotional activities. TSSM demand-side strengthening activities consisted of the following:

1. A mass media campaign including: (i) radio advertisements that feature a short jingle about the importance of sanitation, and (ii) a soap opera during a primetime slot on two radio channels with 15 minute episodes covering promotional messages for both latrine upgrading and handwashing behavior.

2. Wall murals, posters and flyers with the _Choo bora chawesekana_ slogan providing information on pricing, simplicity and the benefits of the “ _sungura_ ”<sup>19</sup> slab constructed by masons trained in the program (see Figure 4 for an illustration).

3. A roadshow (DCC event) promoting improved sanitation which would include skits, competitions, music, dancing, and _sungura_ slab sales promotions.

4. CLTS triggering and the creation of a sanitation committee.

Beyond lack of demand, formative research developed to inform the intervention design identified limited availability of low-cost, durable sanitation options as being prominent challenges to the success of the intervention in rural communities. Furthermore, masons exhibited limited business and marketing skills. To overcome these constraints, demand-side interventions were accompanied by supply-side strengthening to ensure local provision of latrines and sanitation products. The program trained masons, or _fundis,_ in latrine construction and marketing skills. The training lasted a week and taught masons how to build _sungura_ cement sanitation platforms to be sold for approximately $5 per slab. Masons were also taught more general techniques for upgrading latrines together with basic marketing and management skills to guide their operations. The aim of the training was to enable masons to capitalize on the demand for sanitation products generated by the promotion activities, and to spur future demand.

> 19 Sungura means rabbit in Swahili and refers to the appearance of the slab

10
A year into the program, limited availability of materials was creating bottlenecks in the process, which led to the decision to introduce a supply chain strengthening component aimed at incentivizing local distributors (hardware stores) to make the materials required for cement slabs more readily available to masons to use as inputs.

# **_2.4._** _Handwashing with Soap_

The handwashing with soap (HWWS) intervention targeted rural mothers with children under 5. The program conducted extensive formative research on barriers to handwashing with soap, and used the results to inform the design of communication campaigns. Barriers identified include a lack of both time and cues (e.g. handwashing stations) that are helpful in reinforcing habits. In light of these barriers, HWWS promoted an enabling technology called the “tippy tap<sup>20</sup> ” that provides an external cue to handwashing with soap. It comprises a simple handwashing station equipped with water and soap (made cheaply using local materials). The campaign specifically targeted mothers, who are often seen as the guardians of children’s health and wellbeing, and recognized them for their contribution to the family. The campaign was built around an overarching communication concept embodied by the slogan _Mikono Yenye Fahari_ (“Hands to be proud of”), which was designed to tap into mothers’ aspiration for recognition for the work they do for families (Coombes & Paynter, 2010).

The campaign, which later evolved into _Asante Mama_ (“Thank you mother”), formed the backbone of the district-level activities. Activities of the program included mass media interventions (radio adverts and soap opera); branded intervention material (posters, hats, clothing, etc.); DCC roadshow events (similar to the TSSM interventions); and interpersonal contact (IPC) through front-line activators (FLAs), or _Msabunashajis_ ,<sup>21</sup> who are trained to visit households and conduct handwashing promotion events with women on market days, during prenatal clinic visits, and at village meetings FLAs would also distribute promotional material including flyers and comics on how to construct a tippy tap, and a wall calendar used to remind households of the times to watch the soap opera.

The program identified volunteers from each community and provided them with a 3-day-long training structured around pathways for contamination and advocating appropriate hygiene practices related to handwashing with soap (including the best methods to follow and critical junctures). FLAs were subsequently taught how to effectively engage with the community, relay campaign messages to caretakers, and successfully monitor hygienic practices in the village. They were trained in tippy tap construction, and were expected to impart this learning to village households, with caregivers of young children as their primary target.

> 20 For more information on tippy-taps and other enabling technologies, see www2.wsp.org/scalinguphandwashing/enablingtechnologies.

> 21 Roughly translated as “The Soaper”

11
The HWWS DCC events targeted mothers and stressed the importance of ensuring the cleanliness and health of children, which required washing hands with water and soap at critical junctures. People were shown how to construct a tippy tap and given a chance to try using one. The FLAs reinforced this message in their interaction with caretakers. The HWWS DCC event was otherwise implemented in the same manner as the TSSM DCC activities.

# **_2.5._** _Program Implementation_

WSP worked in collaboration with Tanzania’s Ministries of Health and Social Welfare to develop the TSSM and HWWS campaign materials and trained district government counterparts who in turn conducted training of local FLAs, CLTS facilitators and masons and coordinated the distribution of marketing materials. DCC events were implemented by private companies (separately for the HWWS and TSSM campaigns). The objective was for the Tanzanian government to have overall oversight and control of the program implementation for sustainability purposes.

TSSM and HWWS promotional campaigns were phased in between February 2009 and December 2010 across 10 rural districts: Mpwapwa, Kondoa, Rufiji, Iringa, Sumbawanga, Kiteto, Masasi, Musoma, Karagwe and Igunga. The two interventions were implemented separately – in this case the combined intervention implied the overlapping delivery of both interventions, rather than a coordinated hybrid of the two. A timeline of activities is presented in Figure 5. The mass media campaign ran from February 2009 – December 2010 across the country and became a joint TSSM/HWWS intervention; 15 minute radio slots discussed issues related to both sanitation and hygiene. Distinct HWWS and TSSM DCC roadshows and other marketing materials were initially rolled out from June 2009 – June 2010. However, two separate DCC campaigns were conducted for the HWWS intervention, in contrast to only one for the TSSM intervention. The first campaign ran from January – June 2010 and the second ran from August – October 2010. Mason and FLA training took place early on in the campaigns (June 2009 – March 2010). Masons were then ready to meet the newly generated demand for sanitation following the implementation of CLTS triggering and DCC events in the latter half of 2009 and early 2010. Similarly, FLAs were in place to reinforce HWWS messages.

The mass media radio campaign was broadcasted across the country on two of the major radio channels. A total of 80 15 minute soap opera episodes and 1800 radio adverts of 45 seconds each were aired, reaching an estimated 10 million people. Since the radio campaign reached all wards, irrespective of treatment assignment, it was not directly evaluated and all results in this paper can be interpreted as the effect of the TSSM/HWWS interventions at the ward level in the presence of a radio campaign.<sup>22</sup>

> 22 In a nested experiment we attempted to unpack the effect of the mass media campaign by conducting a randomized encouragement design which provided one third of HWWS households with a calendar or comic mentioning the date and time

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Table 2 summarizes the reach of the various intervention components based on project monitoring data. For TSSM, 407 masons were trained across all treatment villages. A further 282 CLTS facilitators were trained and conducted CLTS triggering in a total of 79 wards.<sup>23</sup> All TSSM villages received murals and/or posters, and 81 out of the 90 originally assigned wards received the DCC event<sup>24</sup> reaching a recorded 180,000 people.

For the HWWS campaign, 433 FLAs were trained across all of the treatment villages. The DCC event missed 5 of the 91 assigned wards, reaching an estimated 220,000 people during the first round and 234,000 in the second round.<sup>25</sup>

# **3. Experimental Design**

# **_3.1._** _Identification Strategy_

Tanzania is administratively separated into 30 regions, 169 districts and 3,643 wards, with the average ward holding approximately 12,000 people. To evaluate the impact of sanitation, handwashing and combined interventions, we implement a cluster-randomized evaluation with random assignment of interventions at the ward level, including a total of 135 intervention and 46 control wards. Wards were identified as the optimal operational unit of implementation for the project, and of sufficient geographic extension to minimize the risk of significant information spillovers between populations exposed to the localized messages, community events, and other forms of social promotion activities.

The sample was drawn from 10 districts spread throughout the country selected by the Ministry of Water (MoW) and Ministry of Health and Social Welfare (MoHSW) to provide geographic diversity at the national level (see map in Figure 6). These districts are not random, and were targeted because of operational feasibility for program implementation, taking into account the existence of ongoing MoW and MoHSW projects, including the Health Village Campaign (HVC) and water and sanitation interventions. Of the 245 wards in these 10 districts, initially 13 wards were dropped from the sample. Three of these wards were urban, and thus ineligible for the program, and the remaining 10 wards were pre-selected as pilot areas for the program and excluded from the evaluation. Among the remaining 232 wards the program selected the 190 largest wards by population size in order to maximize the population under treatment. These 190 wards were subsequently randomly assigned to one of four groups: (1) Handwashing intervention, (2) Sanitation intervention, (3) Handwashing and Sanitation intervention, and (4)

> of the soap opera. We find this had a positive but non-significant increase in recall of the soap opera which was not a large enough effect to be able to measure subsequent impacts of the campaign through the encouragement.

> 23 While 90 wards were assigned to receive CLTS, 11 were not treated due to logistical challenges of district facilitators training and visiting wards, with lack of funds for the district facilitator to travel cited as the reason for non-compliance.

> 24 Imperfect compliance resulted from logistical constraints of reaching villages during the roadshow schedule

> 25 It is not possible to compute how much overlap there was between the first and second round, but it is expected that these numbers mostly reflect repeat exposure since the events were conducted in the same villages in both rounds.

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Control (no intervention). After the initial sample selection, the district of Massasi experienced a re-districting process through which 9 wards were reassigned to a neighboring district which was not part of the program and were dropped from the sample. The reassignment was balanced across treatment arms and included 3 wards from the sanitation only group and 2 wards from each of the other study arms resulting in a final experimental sample of 181 wards.

We implemented a block randomization procedure within districts with the objective of balancing the population sizes of treatment and control wards within each district. First, wards were ordered by population size within districts and blocked into groups of four, starting with the four most populous wards, second most populous, and so on. A random number was then assigned to each ward, and a group number between 1 and 4 was given to each ward based on the ordering of the random number within its respective block. Finally, group numbers were randomly assigned to represent one of the three treatment or control groups.<sup>26</sup>

# **_3.2._** _Compliance_

Table 3 presents treatment compliance at the ward level. Of the 181 wards selected for the sample, 45 were assigned to handwashing, 44 to sanitation, 46 to the combined intervention and the remainder to control. According to administrative records, the implementing agency accidentally conducted handwashing promotion in one of the sanitation wards, resulting in actual delivery of TSSM only to 43 wards and combined TSSM and HWWS to 47 wards. There were no reported deviations from the planned implementation of mason or FLA training, and no information was available to assess the actual delivery of village-level media (wall drawings, posters, etc.), although, based on information from the field managers, we expect that a majority of the print material dissemination was implemented as scheduled. Within each ward, the two largest villages were targeted for program implementation.

Administrative records of program implementation determined that some wards received only partial treatment. 2 of the 45 HWWS wards were not exposed to the DCC event, 7 of the 43 TSSM wards did not have a CLTS triggering, and 5 of these 7 wards did not receive the DCC roadshow event. Of the 47 wards that were assigned to both TSSM and HWWS, 4 wards did not receive a CLTS triggering or DCC exposure.

# **_3.3._** _Balance_

Table 4 presents balance statistics. Since we do not have a baseline survey, this consists of a combination of time-invariant indicators and retrospective responses asked in the endline dating to February 2009 – before the intervention had started. Of the 87 variables we are able to present for each of the three groups (resulting in 261 comparisons to the control), we find a statistically

> 26 The randomized selection procedure can be obtained by the authors on request

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significant difference in 12 tests for balance at the 5% significance level. The expected number of “by-chance” imbalances from a random draw of 261 is 13, which suggests that this is well within the expected range. However, some concerns persist. Firstly, half (6) of the imbalances are found in the HWWS group, which is more likely to have a cement floor and piped water connection. The sanitation only households are more likely to have a pit latrine with slab or ventilated pit latrine (VIP) in 2009, and the combination ward households are more likely to listen to the radio and have slightly older household members than the control group. The most concerning imbalance for the study is the difference in sanitation coverage between TSSM and the control group. However, there are good reasons to be skeptical about the validity of these imbalances, given that the collected data is retrospective in nature and subject to recall bias. Nonetheless, we run all of the results and include all of the imbalanced variables as controls, with the tables presented in the online appendix. Overall, the TSSM impact on latrine construction and availability reduces, to line up more closely with results found in the combined intervention, but signs and significance remain consistent, suggesting that these imbalances are not driving any conclusions made in the paper.

# **4. Data and Sample**

The sampling procedure, in following program operational guidelines which targeted the two largest villages in each treatment ward, selected the two largest villages, based on population size, in each of the 181 evaluation wards. For the 362 villages in the sample, the full list of census enumeration areas (EAs) was obtained from the Tanzanian National Bureau of Statistics (NBS). For each village, the sample included one EA, selected with probability proportional to size (PPS). A census listing exercise was then conducted in each EA to collect basic information to determine household eligibility for the survey. Survey eligibility criteria were (i) the household was present during the period of listing; (ii) had been living in the village since the beginning of 2009 or earlier; and (iii) had at least one child under the age of five. Ten eligible households were then selected from each EA at random for the sample.

Field work was conducted between May and December 2012.<sup>27</sup> Field teams visited each village for three days. The first day was used to conduct the EA census listing exercise.<sup>28</sup> The census collected data on 72,705 households in the 362 selected EAs. 31% of listed households were eligible for the survey, primarily based on the presence of a child under age five in the household. Field supervisors then ran an in-field, automated randomization procedure to select 10 households at random from each EA to participate in the household survey together with a replacement sample of 5 households to be used in the case of potential non-response. If a household refused to participate or was not available after two visits, the first household in the

> 27 In 2009 a baseline survey was initiated but not completed in 5 of the 10 intervention districts; The endline survey was implemented under an independent sampling scheme, following the original sample design. 28 EA sizes ranged from 51 to 746 households with an average of 221.

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replacement sample was selected. A total of 105 such replacements were made resulting in 3,619 completed interviews from 3,724 attempted (97.2% response rate).

In addition, two of the ten sampled households were selected randomly for structured observations which took place on the second day (resulting in a sub-sample of 724 households). Structured observations consisted of a three hour visit to the household in the early morning (determined by the time the primary caregiver would wake up) where the enumerator would observe caregiver handwashing behavior. This was conducted before any household interviews were held in the village, with the intention of reducing any potential Hawthorne effects that could result from respondents being aware that the intention of the visit was to record handwashing behavior. Enumerators would record the various handwashing “critical junctures” experienced by the caregiver and target child, which include (i) before preparing, serving or eating food and (ii) post-toileting. They would then record whether critical junctures were accompanied by handwashing with soap and water.

Following the structured observations, household surveys were conducted on the second and third days of field work. The questionnaire<sup>29</sup> included modules on demographics, productive activities and assets, water and sanitation status (observed and self-reported), education, hygiene practices and knowledge, social capital, self-reported exposure to the program interventions and child health. Health results were collected for children between the ages of 6 months and 5 years. A description of the priority outcomes is as follows:

**Access to an improved latrine** : The variable construction follows the JMP improved sanitation definition based on observed latrine type and private ownership. Based on a specific interest of the Tanzanian Government, we also consider how access to an improved latrine varies when we include shared facilities, or expand the definition of sanitation quality as being fulfilled by only one squat hole with a slab that does not expose contents.<sup>30</sup> For households with latrines, we also ask when the latrine was constructed to determine whether this was done during the intervention period. While a small number of households may have flush/pour facilities, including septic tanks, we refer to “latrine” construction since 97.5% of households with a toilet facility are referring to some form of pit latrine.

**Open defecation** : This is a measure of households that report using “no facilities” as the usual defecation practice (as per JMP guidelines.) We present a second definition that asks households directly whether they practice open defecation always, sometimes, rarely or never. We then present these results as a measure of intensity.

> 29 Based on the global WSP survey instrument applied for HHWS impact evaluations in Senegal, Peru and Vietnam and TSSSM evaluations in India and Indonesia.

> 30 see http://www.wssinfo.org/definitions-methods/watsan-categories for the formal JMP definition

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**Caregiver handwashing practices:** These were collected based on self-reported information and structured observations. Given the potential courtesy bias associated with self-reported measures, we consider self-reports as reflecting knowledge rather than practice. For structured observations we measure whether the caregiver uses water and soap to wash her own or her child’s hands in conjunction with the following exposure events:

- **After fecal contact:** (i) after defecating; (ii) after toileting; (iii) after cleaning child posttoileting

- **Before handling food:** (i) before cutting or preparing food; (ii) before eating; (iii) before serving food; (iv) before breastfeeding.

**Diarrhea** : From the household data we use a caregiver-reported symptom-based measure defining 7 day diarrhea prevalence as having 3 or more loose/watery stools in a 24 hour period or having a stool with blood or mucus (Baqui _et al._ , 1991). To ensure consistency with the 2010 DHS, in the listing survey we ask caregivers of 34,045 children (under 5 years) a question on whether children have had diarrhea in the past 14 days.

**Anemia** : Anemia status (iron deficiency) was collected using a HemoCue<sup>TM</sup> Hb 201+ photometer, which measures blood hemoglobin levels in real time. These biomarkers were collected for all children between 6 months and 5 years old in the household. In line with WHO guidelines, we consider children to be anemic if their hemoglobin concentration is below 110 g/L, (WHO, 2011).

**Anthropometry** : Child height, weight and head circumference were collected by specially trained enumerators with a nursing background, who followed WHO anthropometric data collection protocols to assess malnutrition levels. Results are transformed into height-for-age, weight-for-age and head circumference-for-age standardized z-scores based on WHO international growth standards.

# **5. Econometric Specification**

We estimate the intention-to-treat (ITT) estimator as the difference between average outcomes across treatment and control groups. The basic specification is: Where, _Yij_ is the outcome of interest for household or individual _i_ in ward _j_ , _Tjk_ is a dummy variable equal to 1 in wards assigned to receive treatment _k_ where _k_ = {1,2,3} for HWWS, TSSM and the combined intervention respectively. _βk_ is the estimate of the average effect of treatment _k_ . _S_ **_jl_** is a dummy variable equal to one if Ward _j_ is included in block _l,_ representing the 17
block fixed effects for the 48<sup>31</sup> stratified ward blocks included to improve precision (Bruhn & McKenzie, 2008). For child-level outcomes we include age and month dummies as covariates. Standard errors are clustered at the ward level. We then check whether the impacts of the three treatment arms are statistically different from each other by presenting F-statistics to test whether we can reject the null hypotheses: _β1_ = _β2_ ; _β1_ = _β3_ and _β2_ = _β3_ . The p-values associated with these tests are reported in all of the regression tables.

In addition to the basic specification, we estimate the following models: (i) include control variables to reduce residual variance and account for any baseline imbalance<sup>32</sup> and (ii) estimate the local average treatment effect for receiving the program, by instrumenting random assignment on actual implementation based on program monitoring data. These additional specifications are presented in the online appendix.

# **6. Results**

For all household- and caregiver-level responses, the tables present the specification that includes block fixed effects only. For the child health indicators, the specification presented includes block fixed effects together with child age (month dummies) and gender controls. In addition we include the full set of models in the online appendix.

# **_6.1._ Program Exposure and Outputs**

Table 5 shows impacts on self-reported program exposure to TSSM and HWWS channels, with large and significant differences in the probability of being exposed to one or more messages among the three treatment groups. Three channels are included for HWWS and TSSM. Both interventions include promotional materials (which can include wall drawings, posters and comics) and participation in respective DCC events. The third channel of exposure to HWWS includes being visited by an _msabunashaji_ /front-line activator, while for TSSM it includes attending a CLTS event. 22.4% of households in the control group report being exposed to any TSSM messages, while this proportion increases by 14.1 percentage points in the TSSM-only group, by 25.1 percentage points in the handwashing-only group, and by 34.5 percentage points in the combined group. When measuring the number of events recalled, we find a nearly linear relationship with the number of DCC triggering activities in each group (1 in the TSSM group, 2 for the handwashing, and 3 in the combined group), suggesting that the frequency of program activities is strongly related to message exposure and recall.

> 31 Not all districts have ward numbers divisible by 4, in which case some blocks contain only 2 or 3 Wards.

> 32 We use the variables found to be unbalanced across intervention groups. This includes: (i) whether the household had a pit latrine or VIP at baseline; (ii) whether household members listen to the radio; (iii) household asset ownership; and (iv) whether the household has access to piped water.

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While virtually no one in the control group reports exposure to all three channels, 10 percent of households in the combined treatment group do. Impacts on exposure to HWWS messages show a similar pattern to TSSM. We find increases of 37 and 44 percentage points respectively, off of a control mean of 13.5%, for households reporting exposure to one or more channels in the HWWS and combined wards, while around 6% of households report exposure to three channels.

We also ask households if they are aware of the presence of a CLTS committee in the village. Table 6 reports an approximately 13 percentage point increase in awareness among households in TSSM and combined wards, and a positive and significant 6 percentage point increase in handwashing only wards. Compared to control areas, where only 12 percent of households report knowing of a CLTS committee, awareness in sanitation areas is almost doubled as a consequence of the program. Similarly, when asked if they are aware of a mason in the community, households report an 18 percentage point increase above the 14% awareness level in control villages, implying a relative increase of 128%. Reported awareness of a mason in handwashing only wards also increases significantly, but by 9 percentage points. Lastly, when asked whether the household thinks everyone in the village knows someone who could help build a latrine, there is a significant increase of 7 to 8 percentage points in TSSM treatment areas but no impact in HWWS-only wards.

The presence of reported exposure to TSSM messaging in HWWS-only wards and vice versa can be expected given imperfect recall a year and a half following the implementation of the interventions. This is exacerbated further by the fact that the second HWWS DCC event was conducted more recently than the TSSM activities. Furthermore some messaging content in both the TSSM and HWWS shared similar features, for example with regards to hygiene behavior. That said, as we will see in the results that follow, impacts on final outcomes such as latrine construction are much more consistent with the intervention models, suggesting that this reporting may reflect imperfect recall rather than real contamination.

# **_6.2._ Impacts on Latrine Construction and Open Defecation**

The primary objective of the sanitation intervention was to increase the coverage of improved latrines and reduce open defecation. This could happen through upgrading of existing latrines, or building new ones. Since it was believed that basic pit latrine coverage was high in Tanzania, the TSSM campaign focused on simple ways to upgrade latrines, for instance, by incorporating the concrete _sungura_ slab. However, latrine construction in Tanzania is a fairly frequent activity, with 57% of control households reporting the construction of a new latrine in the last 3 years (the period since the start of the intervention) and while we find limited evidence of households trying to upgrade existing latrines, we find strong evidence of households deciding to build new, private facilities. As a baseline falsification test we estimate the impact of the program on the probability of latrine construction in the baseline period, prior to the start of the intervention, and find no association between the program and pre-intervention latrine construction (Table 7).

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The TSSM intervention produces an 8.2 percentage point increase in the probability of building a new latrine in the TSSM only wards, and a 7.7 percentage point increase in the combined wards; these two effects are not significantly different from one another. The effect in handwashing only wards is not significantly different from the control group. New latrine construction is primarily from private rather than shared latrines. The probability of constructing a new private latrine increases between 10 and 12 percentage points above 38% of control households that build new private facilities over the intervention period. Consistent with this result, we find that the probability of sharing a latrine with another household falls by 9.2 and 7.6 percentage points in the TSSM and combined wards respectively.

As expected, we observe no impact of the HWWS intervention on the probability of constructing new private latrines. Unexpectedly, however, there is a significant reduction of about 4 percentage points in the construction of shared latrines in HWWS and TSSW only wards, and an insignificant reduction in combined wards. This may result from household decisions to shift from the construction of shared latrines, to the construction of private ones.

The increase in latrine construction in TSSM wards translates not only into more private latrines but also better quality ones. Table 8 shows that the probability of using improved sanitation increases in both TSSM and combined treatment wards, irrespective of the definition for improved sanitation employed. The use of _sungura_ slabs is still low, but increases significantly in the intervention wards from 1.4% in the control areas to 7% and 4.6% in the TSSM and combined wards.

Through behavior change and increased presence of latrines, one of the program’s primary sanitation objectives is the reduction of open defecation. Consistent with this objective, we observe large and significant reductions in open defecation in both the TSSM and combination groups. While 23.1% of households report open defecation as the primary form of feces disposal in the control group, this is reduced by 12 percentage points in TSSM only wards and by 7.4 percentage points in combination wards. As presented in Table 9, the majority of the reduction in open defecation is from regular to less frequent open defecation, rather than complete cessation. 51% of households report at least some open defection in the comparison group and the likelihood is not statistically different in the treatment arms. Given the important externalities associated with sanitation and defecation practices, it is useful to understand how this translates into community-wide practices. Community leaders were asked whether the village had been declared open defecation free (ODF). Consistent with the findings on latrine construction and household open defecation, we find a significant increase of 12.7 and 8.7 percentage points in TSSM and combination villages respectively from 5.4% of control villages claiming to be ODF. There is a positive but insignificant increase of 4.6 percentage points in the proportion of ODF HWWS villages. Using the fact that we have a sample of 10 households per village, we can also estimate village-level open defecation prevalence by aggregating household responses. Figure 7 presents the cumulative distribution functions for village-level regular open defecation in each 20
intervention group. Figure 8 shows the same distribution for households practicing at least some open defecation. Consistent with the previous findings we observe large improvements in village-level regular open defecation across the distribution for TSSM and combination wards, but very little (insignificant) differences for village households practicing open defecation some of the time. The distributions of these two indicators are also strikingly different. For instance, almost all villages have at least some households practicing some open defecation, which increases roughly linearly. In contrast, more than half of the sampled villages have nobody practicing _regular_ open defecation. A further 25% of villages have between 0% and 20% regular open defecation prevalence. The results highlight the fact that the intervention is successful in shifting behavior, but this does not result in complete cessation of open defecation which remains pervasive.

We also ask whether the household perceives that people in the community practice open defecation and we find that this perception falls in all groups by just over 5 percentage points below the mean of 84% in comparison communities. Finally, we observe an increase in the probability of correct child feces disposal, as per the JMP definition, in both sanitation treatment groups. We are concerned that results from the TSSM group may be driven by possible baseline imbalance. Controlling for baseline latrine type, we find positive TSSM results reduce slightly and converge to be more closely aligned with combination ward results, with signs and significance tests remaining the same with and without controls. These results are found in the online appendix.

# **_6.3._ Impacts on Handwashing Knowledge and Behavior**

We now turn to the impacts on handwashing related outcomes. We generate an index from 0 to 1, which signifies the proportion of 5 unprompted handwashing junctures of which the caregiver is aware– after going to the latrine; after washing baby’s bottom; before preparing food; before eating; before feeding/breastfeeding. We find that caregivers in the handwashing and combined groups show small but significant improvements in knowledge (Table 10). When inquiring whether the caregiver knows that handwashing with soap and water is the best method we observe an increase of over 5 percentage points in TSSM and combined wards, and unexpectedly no significant impacts in the HWWS only group. However when we turn to self-reported handwashing with soap in the last 24 hours we do not see a significant change in any of the treatment areas relative to control. Furthermore, while the presence of soap by a handwashing station is 8% in the control group, this proportion is unchanged in the handwashing and combined wards and actually declines slightly (significant at the 10% level) in TSSM wards. Households in the TSSM and combined group report higher expenditures on soap in the last month.

The intervention does not have an impact on the probability of having any form of handwashing station, including mobile stations, regardless of whether soap is present (48% of households do), 21
but does have a relatively large impact on the probability of having a fixed handwashing station and a handwashing facility within 6 meters of the latrine in combined intervention wards. While only 1.2% of control households have a fixed handwashing station, this proportion increases by 1.7 and 2.8 percentage points respectively in HWWS and combination groups. Most of this change is driven by the presence of “tippy taps”, which we include as fixed handwashing stations. While statistically significant, these numbers remain small – a total of 22 tippy taps were observed in the entire sample, which questions the sustainability of this intervention.

Only 3.7% of control households have a handwashing facility within 6 meters of their latrine, and this proportion increases by 6.3 percentage points in combination wards (but not the stand alone groups). Though in absolute terms the presence of latrines with handwashing facilities in combination wards is still relatively small (about 10% of households), this result may reflect an interaction of the TSSM and HWWS interventions whereby households exposed to both types of messages are more likely to install new latrines with a handwashing station nearby.

To measure handwashing practice we utilize both direct observation of handwashing at critical points in time in the household, as well as self-reported measures. The number of exposure events identified through direct observation is very similar across groups and not statistically different, with an average of 5.8 exposure events observed per household. Overall, we find no differences between treatment and control groups in self-reported or observed handwashing with soap after fecal contact (Table 11). Moreover, while 47% of respondents report washing hands after fecal contact in the last 24 hours, only 12% of individuals washed hands after fecal contact in the direct observation sub-sample. The likelihood of observed handwashing with soap after fecal contact actually declines by 5.6 percentage points in TSSM wards, though this is likely related to the increased opportunity for observing otherwise unobserved handwashing behavior in households with new latrines constructed following the TSSM intervention. That being said, there is no significant decrease in observed handwashing in combination wards.

While there are no significant impacts of the program on handwashing behavior after fecal contact, we do find small increases in self-reported and observed handwashing practice before preparation of foods. There is a 7.7 percentage point increase in self-reported handwashing before food preparation in the HWWS group over the 15% reported in the control group (and no significant impacts in the TSSM or combination groups). In the direct observation sample, there is a 1.6 percentage point increase in the likelihood of observing handwashing when handling food or feeding among members of the HWWS and combination groups, over a mere 1.3% of handwashing observed at this junction in the control group.

Beyond the small positive impacts on handwashing prior to food handling, results from the direct observation of handwashing practice are not encouraging. For any exposure event observed by the enumerator, 27% were followed by any form of handwashing in the control group with no significant differences compared to any treatment group. Only 3.8% of exposure events were 22
followed by handwashing with soap and water, and again there are no statistically significant differences between the control and treatment groups. These results report on the full sample of individuals and observed events are largely unchanged when focusing on the behavior of the child’s caregiver or the average household behavior (see online appendix).

# **_6.4._ Impact on Other Hygiene Practices**

In addition to handwashing behaviors we measure other indicators related to hygiene practices in the household, including the observed cleanliness of children and caregiver’s hands, observed animal or human feces around the house and living area, smell of feces around the house, presence of garbage, and whether food is covered. Overall, children appear to be cleaner in the HWWS and combination wards. We combine three binary indicators: whether the child has dirty hands, fingernails or face, to generate an index from 0 (dirty) to 1 (clean), which increases from a base of 0.56 for children in the control group, by 0.077 and 0.069 points respectively in the handwashing and combination wards. The results are consistent for each individual indicator comprised in the index, amounting to an increase of 5 to 8 percentage points in the likelihood of being clean across each of the three dimensions. The caregiver hand cleanliness index also shows improvement in handwashing and combination wards. Enumerators rate cleanliness on a scale of 1 (visible dirt), 2 (unclean appearance), or 3 (clean) for nails, palms and fingerpads of caregivers separately. The scores are summed to get a value between 3 and 9. We observe an increase of about 0.4 and 0.45 points in the handwashing and combination wards respectively, above a mean score of 6.7 in the control group. No changes are observed in TSSM wards.

We observe no changes in the probability of observing human or animal feces around the home (9% of households), smell of feces around the house (12% of households) or observed loose garbage in the kitchen or house (38% of households). There is a large and significant increase, however, in the likelihood that food is completely covered. While food coverage is observed in 28.3% of control households, this proportion increases significantly in all three treatment groups, with magnitudes ranging from 11.1 percentage point increase in the handwashing only group to 6.8 percentage points in the combined treatment group (impacts are not significantly different between groups).

Finally, with regard to sanitation-related behavior we find that households with latrines in the TSSM and combined groups are more likely to report having ever cleaned the latrine they use, an increase of about 7 percentage points above 80% of households that report this behavior in the control group. Furthermore, there is a reduction in the probability of observed feces in the latrine or outside of the pit in combination wards. We find a reduction in feces observed in the latrine areas outside the pit, from 22% in control households to 17.7% in treatment ones. However, there are no significant differences in the reported presence of flies in the latrine area (53.7% of households report flies being present all the time).

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# **_6.5._ Health Outcomes**

The TSSM and HWWS interventions are aimed at provoking handwashing and sanitation related behavior change with the ultimate goal of improving the population’s health, particularly health outcomes amongst children under 5. These results are presented in Table 13. We analyze the program’s impact on the probability of diarrhea in the past 7 and 14 days as a short term measure of health from exposure to pathogens; hemoglobin levels/anemia and weight as medium term measures of health; and height and head circumference as longer term indicators of the cumulative effects of improved health.

For the analysis of diarrhea we use the large-scale household listing survey measuring the existence of one or more diarrheal episodes amongst children under 5 in the past 14 days (n= 34,045), as well as the caregiver report during the in-depth household survey on symptoms of diarrhea amongst children under 5 (n=5,768). The diarrhea incidence from the listing data includes a much larger sample size and a longer time horizon when compared to the in-depth household survey data, thereby providing more power for the measure of impacts on this variable. Using the listing data, we estimate a decline in diarrhea of 2.1 percentage points (significant at the 10% level) in the combined treatment group, which constitutes a relative reduction of 12.5% compared to the control group where 16.8% of children are reported as having had diarrhea in the past 14 days. The estimated coefficients in the TSSM and HWWS only groups are negative but insignificant. However, when we analyze the household selfreported outcomes on diarrhea symptoms in the past 7 days we observe no significant differences between treatment and control groups. Diarrhea symptoms are reported for 8.6% of children in the control group, and while the coefficients on the three treatment groups are negative, they are small and statistically insignificant.

Hemoglobin (Hb) levels test for the presence of iron-deficiency anemia, which proxies for the child’s nutrient intake and absorption. Nutrient absorption can be affected by intestinal pathogens that reduce the absorptive capacity of the child’s intestinal tract. We observe no differences in either the level of measured Hb or the probability of anemia for children in the TSSM and HWWS only groups. However, in the combined treatment group, children show a small but significant decline of 1.65 g/L in hemoglobin (a 1.5% relative decline compared to the average of 111.4 g/L in the control group) and a significant increase in the probability of being anemic (defined as Hb<110 g/L), 6 percentage points higher than the 41.4% incidence observed in the control group. A second indicator that does not change in the singular treatment arms is weight-for-age (z-score), an indicator of children’s short term health. The average weight-for-age z-score in the combined intervention group declines by 0.075 standard deviations off of an average weight-for-age z-score of -1.03. Although biologically insignificant, the unexpected direction of the effects of the program on children’s health, as measured through anemia and weight, particularly in light of reduced presence of diarrhea in the same population, is a puzzle that we explore further in the next section.

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Finally, our indicators for long run child health are the height-for-age z-score and head circumference-for-age z-score. On average we find no effects of the program on the height of children in any of the treatment groups relative to control and estimated coefficients are close to zero. For head circumference, estimated coefficients are positive but not significant (0.2 standard deviations in the handwashing groups). Thus, we conclude that the HWWS and TSSM interventions did not have a detectable impact on the long-term health status of beneficiary children.

# **_6.6._ Subgroup Analysis: Child Age**

The time in a child’s life during which he or she is exposed to a WASH intervention is likely to be an important determinant of the potential effects the intervention may have. For instance, stunting is the long-term effect of reduced nutrition at the earliest years of life, where growth faltering is most common. Younger children with less developed immune systems may also be more susceptible to disease in early life. When we separate our analysis into “younger” (ages 0, 1 and 2) and “older” (ages 3 and 4) age cohorts, we find little difference in height-for-age measures (Table 14). Absolute reductions in diarrhea for the combination wards are largest in the youngest age group, where we find a 2.6% reduction off of a control mean of 20.4%, compared to an insignificant 1.3% reduction off of a 10.6% control mean for ages 3 and 4, although the relative change is somewhat similar at 12.75% and 12.25% respectively. None of these results are statistically significant for either cohort in the TSSM or HWWS wards.

In the same age cohorts we find a larger reduction in hemoglobin levels for the younger group (- 2.35 g/L) and a much smaller and statistically insignificant reduction in the older group (- 0.47g/L) in combination wards. Similarly, weight-for-age reductions are stronger in the younger cohort. None of the results are statistically significant for either cohort in TSSM and HWWS wards.

It is important to note that this sub-group analysis was not included as part of a formal preanalysis plan, and we did not stratify by age cohort in the randomization procedure, although we do find baseline balance in child and household characteristics between control and treatment wards in these subgroups. The results suggest that most of the health effects are being driven by the younger cohort.

# **7. Validity Checks**

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We may be concerned that the counterintuitive health results could be driven by data quality issues. Here we explore these concerns in relation to diarrhea (7 and 14 day prevalence), hemoglobin level,<sup>33</sup> height-for-age, weight-for-age and head circumference z-scores.

# **_7.1._ Courtesy Bias**

While the nature of the intervention made it impossible to blind participants to their treatment status, we ensured that interviewers were blinded to the intervention status of each village in an attempt to reduce potential courtesy bias.

Objective biomarker measures help to overcome the potential of courtesy bias, which has been documented in previous literature related to WASH interventions (e.g. Schmidt, 2014; DFID, 2013). To test for potential courtesy bias in self-reported measures, we include a falsification question in the child health calendar survey instrument on whether the child has had abrasions, scrapes or bruising in the past 7 days, which we would expect to be uncorrelated with the handwashing or sanitation interventions. Results are presented in Table 15 and we find a small and borderline significant decrease in the combination ward, but no effect in the TSSM or HWWS wards suggesting potential but limited concern for reporting bias in the combined group.

# **_7.2._ Nonrandom Covariate Imbalances: Enumerator Bias and Differential Timing**

Biometric measures are able to remove any potential subjective reporting bias, but we may still be concerned about non-random measurement bias given the level of skill required to measure height, weight, head circumference and anemia levels. We may also be concerned that roll-out of the survey (nine months in total) may have resulted in control and treatment households being visited at different times in the year. This would be problematic in cases where outcomes are seasonal, such as for anemia, which manifests as a symptom of malaria. We run all of the regressions for health outcomes (Table 15), and include interviewer and interview month fixed effects to account for these potential biases. We find that results remain consistent and significant for diarrhea, weight-for-age and hemoglobin level, while remaining small and insignificant for height-for-age. In fact, impacts increase slightly in all cases, and the standard errors reduce, yielding more precise estimates. Head circumference results vary somewhat across specifications, bringing into question the accuracy of this measure.

# **_7.3._ Outliers**

> 33 Being anemic is based on the cutoff of having less than 110 g/L of hemoglobin in the blood. We find that, although significant, the result is highly influenced by the cutoff level chosen, and any cutoff between 73 and 103 g/L would fail to reject a difference in means between the control and combination group (Figure 9). In this case, we prefer to conduct robustness on the raw hemoglobin levels.

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Removing observations larger than 3 standard deviations from the mean for anthropometric measures discards 41, 33, 61 and 74 observations from the hemoglobin level, weight-for-age, height-for-age and head circumference z-scores respectively. Rerunning these regressions with this limited set (along with other similar specifications) yields results virtually unchanged from the original, except in the case for Hb level, where the impact is reduced and is no longer significant (Table 15). This is consistent with Figure 9 which indicates that most of the anemia change is coming from a small reduction in Hb levels close to the cutoff of 110 g/L, but there is also a left-hand tail in the combination distribution of severely anemic children (which are removed as outliers in this specification). Care should be taken when interpreting this result since removal of these outliers in the case of Hb levels may exclude important information regarding the treatment impact on the distribution of anemia.

# **8. Potential Mechanisms**

While the generally accepted theory of change (and the one on which this study was originally based) provides clear justification for why we may expect to find positive health outcomes, it is less clear what may drive negative health outcomes. Here we consider three possible explanations: (i) differential mortality; (ii) contamination of groundwater; and (iii) poor latrine quality.

# **_8.1._ Differential Mortality**

Lee _et al._ (1997) present a framework to describe how we may find negative health effects of water and sanitation interventions in high mortality settings. If the intervention reduces mortality, this may have the perverse effect of increasing the proportion of sick children, who would have otherwise died absent the intervention. If this differential selection is not accounted for, our health impacts will be biased downwards. We test for this possibility with the listing data available. If differential mortality is affecting health outcomes, we would expect a lower mortality rate in the treatment wards. While we do not have appropriate mortality measures, we do have data on the number of children under 5 in each of the 50,885 households asked this inclusion question during the listing exercise. We find no difference across any of the groups (Table 16). Child mortality may induce a fertility response, with mothers being more likely to have another child if their child passes away, thus equalizing under 5 ratios across groups. If this were the case, however, we would expect to see differences in the age distribution across groups (e.g. control households having a higher proportion of 0, 1, or 2 year olds). We run the same regression on each age group and find no evidence of different age distributions across groups, suggesting that selective mortality is not a concern in our data.

# **_8.2._ Contamination of Groundwater**

Non-experimental research suggests a possible link between pit latrines and contamination of groundwater through seepage (Dzwairo _et al._ , 2006). Increasing latrine coverage could then have the potential negative effect of increasing exposure to pathogens through drinking water. In this 27
case, we would expect to find a differential impact of the program depending on whether households treat their water before drinking it. Running sub-group analysis on our health outcomes based on whether the household treats their water (40% of households do), we find no observable differences in health outcomes, suggesting that this transmission mechanism is unlikely (Table 17).

# **_8.3._ Poor Latrine Quality**

An important current topic of debate is whether encouraging households to take their first step onto the “sanitation” ladder by promoting fixed point defecation could be more harmful than helpful, by way of localizing fecal content, bringing it closer to home and providing more opportunity for flies to breed and spread disease. The concern is that, if we encourage households to build latrines, and these latrines are of a very low quality, we may exacerbate contamination opportunities. Our survey instrument has a rich set of measures related to observed and reported latrine quality. Running regressions on a wide range of these variables suggests that there is no clear difference in latrine quality across groups and, if anything, TSSM and combination ward latrines may be slightly better quality than latrines in the control wards, with both groups being more likely to have a squat hole cover in place during the enumerator observation and the combination group having less visible feces surrounding the latrine (Table 17).

# **9. Discussion**

In summary, the results from this study allow us to identify a few important facts to help reflect on potential implications for intervention implementation and future research in this area.

1. **TSSM is able to change behavior but not by enough to significantly influence the level of observed fecal matter:** We see significant increases in improved latrine coverage. However, this does not necessarily translate into a more hygienic environment, and it is not clear that this increase in coverage is enough to make a difference to the daily fecal exposure that children face. While open defecation reduces substantially, the reduction is mostly driven by people limiting regular open defecation, while occasional open defecation does not change significantly and remains high at 51.3% in the control wards. In the TSSM intervention areas, we find fewer than 20% of villages reporting to be ODF. Furthermore, 75% of households have animals and 55% allow these animals into their house. New evidence suggests that children in contact with animal feces face exposure to high levels of bacteria such as _E. coli_ (Ngure _et al._ , 2013), which suggests that a more holistic approach to fecal removal may be required to effectively cut the transmission mechanism. Unsurprisingly, then, observed feces around the dwelling does not change across treatment groups and having a latrine is not correlated with whether feces is observed.

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2. **At-scale handwashing campaigns produce significantly lower effects on health outcomes than efficacy trials. This is likely to result from the limited effectiveness of being able to change handwashing behaviors:** The HWWS intervention presents results consistent with the current literature on large effectiveness trials and suggests that significantly changing hygiene behavior through promotional activities remains a somewhat challenging task. We do find reasonably consistent and positive impacts on a range of hygiene-related indicators, but the magnitude is small and diminishes as we go further along the causal chain. It is clear that there is a large wedge between knowledge and behavior, with 82% of caregivers knowing the importance of washing hands with soap, but only 3.8% of exposure events actually being accompanied by this practice. Current large-scale behavior change campaigns seem unable to effectively close this gap between knowledge and practice.

3. **The tippy taps designed for Tanzania are not sustainable:** Since change in knowledge is not enough to shift behaviors, the presence of visual cues and simplifying the burden of handwashing were promoted through the campaign. This was the rationale for promoting the construction and use of tippy taps. However, while anecdotal evidence suggests that there was initially high take up, we find that only 22 households of a possible 1,829 (1.2%) exposed to the HWWS campaign were using them at the time of follow up.

4. **The messages promoted by the campaigns do not translate into predictable behavior change:** The TSSM intervention promoted the upgrading, rather than construction of new latrines, with the _sungura_ slab being produced by masons as an add-on to current household facilities. In reality households chose to “upgrade” by building their own private latrines rather than sharing with others. HWWS focused on washing hands with soap at critical junctures. There seems to be little evidence to suggest that this resulted in handwashing behavior change, and yet we do find some (weak) evidence on broader measures of hygiene improvements such as latrine cleanliness. This may result from two things: (1) message creep – regardless of how nuanced the design of the message may be, at scale it becomes more difficult to control the delivery of the message (Coombes & Paynter, 2010); and (2) personal interpretation – while designers and implementers may have a clear hypothesis of how we expect people to react, the same information may be interpreted, and acted upon, in different ways.

**5. Combining handwashing and sanitation interventions does not produce clear health benefits:** No detectable health effects are found in the individual interventions. When turning to the combined treatment, diarrhea levels improve marginally, but anemia and weight-for-age outcomes worsen. Putting this in perspective, the anemia and weight-for-age results, while statistically significant, do not seem to be biologically important – they amount to weight reductions of less than

29
100 grams per child on average, and hemoglobin reductions of 1.6 g/L. However, a diarrhea reduction of 2.1 percentage points, when taken at face value, can be considered biologically important, although this measure is only marginally significant (statistically) and does come with reasonable concerns linked to selfreporting, making it less reliable than the biometric markers.

The implications for policy and program implementation require some extrapolation from the data and should therefore be considered only as suggestive. If the primary objective of the policymaker is to reduce child morbidity and mortality, then intervention intensity needs to be considered carefully since there is a tradeoff between going to scale and delivering interventions effective enough to generate health impacts through TSSM and HWWS behavior change campaigns. Exactly how to increase intensity is beyond the scope of this study. Broadly this could focus on doing more of the same interventions more intensively (e.g. multiple follow ups within the same villages) or including a broader range of tools (e.g. sanitation subsidies, animal fecal containment practices).

If, on the other hand, the primary objective for policy makers is increased coverage of improved practices and materials in their own right (reducing open defecation or increasing handwashing with soap), then TSSM seems to be an effective tool to deliver on these objectives, whereas changing behavior through HWWS remains a challenge. In summary, the evidence would suggest that, whichever objective the policymaker seeks to achieve (increased coverage or health improvements), HWWS should be a complementary rather than stand-alone activity.

# **10. Conclusion**

Three systematic reviews over the past decade have shown that handwashing with soap consistently reduces diarrhea by between 39% and 47% (Fewtrell _et al_ , 2003; Curtis & Cairncross _,_ 2005; Ejimot-Nwadiaro _et al_ , 2008). This evidence, however, comes mostly from small-scale efficacy trials exploring proof of concept, or matched studies with high levels of handwashing compliance. While useful, it is not clear how scalable these interventions are, and thus how much national policy can and should draw from this evidence when designing at-scale programs where handwashing compliance is more limited. One outlying piece of recent evidence using emotional drivers in India has found sustained changes in handwashing practices at scale but does not measure resulting health impacts (Biran _et al._ , 2014). Evidence on rural sanitation is less comprehensive, and a series of ongoing evaluations will provide evidence on sanitation efficacy in the coming years. Moving beyond efficacy trials, this study explores, for the first time, what can be achieved _at scale_ through independent and combined sanitation and handwashing campaigns and builds on evidence from the global WSP program looking at the impacts of government-led, at-scale interventions in Vietnam and Peru (HWWS), and India and Indonesia (TSSM). Consistent with the evidence from these evaluations, we find significant improvements in intermediate outcomes resulting from the TSSM intervention (latrine 30
construction and reduction in open defecation) and very limited improvements in intermediate outcomes resulting from the HWWS intervention (building handwashing stations and washing hands with soap at critical junctures). Also consistent with the programmatic evidence, neither intervention on its own is able to measurably improve health outcomes for children under 5. It is only in the combined intervention where health impacts are observed; however the inconsistency in these outcomes and limited biological significance of the point estimates suggest no clear health benefits from the approach.

The results from this study highlight the importance of focusing on intermediate outcomes of take up and behavior change as a critical first step before realizing the changes in health that WASH interventions aim to deliver. Finding the balance between intensity, the right incentives, holistic coordination and scale becomes an important policy question. The biological reasoning behind promoting WASH interventions is theoretically sound, but identifying ways to close the gap between objectives, intervention design and delivery, particularly when working at scale, should be the priority for researchers, policy makers and implementers alike.

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Table 1: Comparison of IE data to nationally representative surveys

|Variable|Source|Source data|IE data|
|---|---|---|---|
|_Demographics_||||
|% HH Head that are Female|DHS|23.4%|13.6%|
|AvgHH size|DHS|5.40|4.90|
|_Housing Characteristics_||||
|_Flooring material_||||
|Earth|DHS|80.9%|82.5%|
|Concrete|DHS|17.5%|14.9%|
|_Cooking fuel_||||
|Paraffin/Kerosene|DHS|0.5%|0.5%|
|Charcoal|DHS|8.5%|8.5%|
|Firewood|DHS|90.1%|91.0%|
|_Access_||||
|HH has access to improved water source|DHS|46.2%|33.3%|
|_Assets_||||
|Electric Generator|DHS|4.3%|1.4%|
|Radio|DHS|57.1%|67.7%|
|TV|DHS|5.3%|2.9%|
|Mobile Phone|DHS|51.3%|58.9%|
|Non-Mobile Phone|DHS|0.2%|0.4%|
|Iron|DHS|19.6%|13.5%|
|Refrigerator|DHS|1.2%|1.3%|
|Bike|DHS|50.9%|62.7%|
|Motorcycle|DHS|4.9%|5.1%|
|Car or Truck|DHS|1.1%|0.6%|
|_Net School Enrollment Rate_||||
|Pre-Primary|National Panel|21.0%|20.4%|
|Primary|National Panel|79.0%|67.9%|
|Secondary|National Panel|20.0%|16.2%|
|Higher|National Panel|1.0%|0.0%|
|_Health_||||
|_Anemia_||||
|% of children under 5 with Hemoglobin<br>less than 8 grams per deciliter<br>_Anthropometrics_|DHS|5.4%|2.1%|
|Height for Age 2SD Below|DHS|44.5%|47.5%|
|Weight for Height 2SD Below|DHS|4.8%|2.5%|
|Weight for Age 2SD Below|DHS|16.9%|15.4%|
|Height for Age 3SD Below|DHS|17.7%|17.1%|
|Weight for Height 3SD Below|DHS|1.3%|0.4%|
|Weight for Age 3SD Below|DHS|4.1%|3.2%|
|Height for Age Mean|DHS|-1.80|-1.95|
|Weight for Height Mean|DHS|0.00|0.02|
|Weight for Age Mean|DHS|-1.00|-1.03|

Notes: DHS = 2010 Demographic and Health Survey; National Panel = Tanzania National Panel Survey (LSMS) 2010 - 2011 36
Table 2: Program outputs

|**District**<br>|**Population**<br>**size**|**Wards**<br>**sampled**|**TSSM /**<br>**Combination**<br>**Wards**|<br>**Masons**<br>**trained**|**Villages**<br>**with**<br>**trained**<br>**masons**|**Number of**<br>**CLTS**<br>**facilitators**<br>**trained**|**Number of**<br>**communities**<br>**triggered**|**People**<br>**reached**<br>**in TSSM**<br>**DCC**|**HWWS /**<br>**Combination**<br>**Wards**|<br>**Frontline**<br>**activators**<br>**trained**|**People**<br>**reached**<br>**in DCC**<br>**(1)**|**People**<br>**reached**<br>**in DCC**<br>**(2)**|
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Igunga|399,727|24|12|42|42|32|282|36,500|12|40|35,509|29,093|
|Karagwe|332,020|24|12|50|49|40|465|21,700|12|46|16,893|39,138|
|Musoma|178,356|24|12|47|48|40|289|NA|12|50|25,441|37,229|
|Rufiji|247,993|16|8|49|46|45|185|34,950|8|45|8,783|14,483|
|Masasi|217,274|15|7|36|34|50|217|28,100|8|42|25,283|13,935|
|Iringa|254,032|12|6|28|30|18|168|15,580|6|28|14,471|15,071|
|Sumbawa|305,846|16|8|40|144|24|211|21,350|8|32|29,219|29,077|
|Kiteto|244,669|8|4|13|30|18|50|5,700|4|53|3,936|10,403|
|Kondoa|269,704|30|15|76|149|5|183|7,600|15|67|24,418|32,016|
|Mpwapwa|305,056|12|6|26|58|10|63|9,200|6|30|36,618|13,631|
|Total|**2,754,677**|181|90|407|630|282|2,113|180,680|91|433|220,571|234,076|

Table 3: Program contamination (monitoring data)

||Planned|Lost Wards<br>(Masasi)|Final<br>Assignment|Contamination|Actually<br>treated|Not triggered<br>byCLTS|Didn't receive<br>TSSM DCC|Didn't receive<br>HWWS DCC|
|---|---|---|---|---|---|---|---|---|
|Control|48|2|46|-|46|-|-|-|
|HWWS|47|2|45|-|45|-|-|2|
|TSSM|47|3|44|-1|43|7|5|-|
|HWWS + TSSM|48|2|46|+1|47|4|4|3|

Notes: no reported problems with (i) mason training or (ii) training of front-line activators (FLAs); no available information for delivery of villagelevel media (wall drawings, posters, etc.) 37
# Table 4: Baseline Balance

||Ov|erall|Co|ntrol||HWWS|||TSSM|||HWWS+TSS|M|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Variable|N|Mean|N|Mean|N|Mean|p-value|N|Mean|p-value|N|Mean|p-value|
|_Dwelling characteristics_||||||||||||||
|A household member owns the dwelling|3618|0.90|918|0.91|900|0.87|0.11|880|0.89|0.47|920|0.91|0.88|
|Household uses a clean form of energy for lighting (electricity,<br>solar, gas or batteries)|3619|0.24|919|0.29|900|0.27|0.72|880|0.20|0.09|920|0.22|0.22|
|Household uses electricity as main energy source for lighting|3619|0.03|919|0.03|900|0.05|0.32|880|0.03|0.95|920|0.03|1.00|
|Household uses paraffin lamps as main lgihting source|3619|0.74|919|0.70|900|0.72|0.68|880|0.78|0.12|920|0.76|0.23|
|Main fuel used for cooking is charcoal|3619|0.08|919|0.08|900|0.12|0.34|880|0.05|0.15|920|0.08|0.77|
|Main fuel used for cooking is firewood|3619|0.91|919|0.91|900|0.87|0.26|880|0.94|0.23|920|0.91|0.94|
|Floor of main living area is made of cement|3613|0.17|919|0.15|897|0.23|**0.04**|877|0.15|0.99|920|0.16|0.69|
|Floor of main living area is made of earth/clay|3613|0.80|919|0.82|897|0.74|**0.03**|877|0.84|0.54|920|0.81|0.73|
|Roof of main living area is made of mud/thatch/grass|3619|0.43|919|0.48|900|0.40|0.16|880|0.42|0.28|920|0.40|0.19|
|Roof of main living area is made of tin/zinc|3619|0.57|919|0.52|900|0.60|0.18|880|0.58|0.31|920|0.59|0.20|
|Walls of main living area are made of brick/cement|3603|0.71|917|0.67|889|0.75|0.22|879|0.73|0.39|918|0.72|0.49|
|Walls of main livingarea are made of mud andpoles|3603|0.28|917|0.33|889|0.24|0.21|879|0.27|0.36|918|0.27|0.38|
|_HH Head Characteristics_||||||||||||||
|Male|3614|0.88|919|0.86|898|0.87|0.87|878|0.89|0.25|919|0.88|0.27|
|Age|3614|40.61|919|39.87|898|41.23|0.10|878|40.19|0.68|919|41.13|0.17|
|Age Squared|3614|1814.22|919|1750.67|898|1865.33|0.14|878|1768.85|0.80|919|1871.16|0.19|
|Ever attended school|3612|0.77|919|0.76|897|0.79|0.34|878|0.79|0.25|918|0.76|0.91|
|Can read and write|3614|0.74|919|0.71|898|0.76|0.13|878|0.75|0.16|919|0.73|0.55|
|Years of Education (if attended school)|2796|6.48|695|6.47|706|6.57|0.43|697|6.44|0.87|698|6.43|0.79|
|Muslim|3618|0.31|919|0.29|899|0.29|0.98|880|0.31|0.78|920|0.35|0.44|
|Christian|3618|0.60|919|0.60|899|0.62|0.79|880|0.62|0.85|920|0.57|0.68|
|Born in this village|3614|0.67|919|0.68|898|0.68|0.90|878|0.64|0.35|919|0.68|0.93|
|Number of years living in this village|1191|18.26|295|17.56|284|18.23|0.64|320|18.61|0.40|292|18.64|0.43|
|Married|3614|0.75|919|0.72|898|0.73|0.77|878|0.76|0.43|919|0.78|0.22|
|Divorced/widowed/separated|3614|0.11|919|0.12|898|0.12|0.97|878|0.10|0.14|919|0.10|0.22|
|Lives withpartner|3614|0.13|919|0.15|898|0.13|0.76|878|0.14|0.87|919|0.11|0.45|
|_HH Member Demographics_||||||||||||||
|HH size at Baseline|3609|4.94|917|4.89|898|4.94|0.82|877|5.02|0.55|917|4.93|0.86|
|Age|22159|17.78|5593|17.47|5482|18.03|0.08|5470|17.52|0.85|5614|18.11|**0.03**|
|Age Squared|22159|597.34|5593|580.72|5482|615.94|0.14|5470|576.69|0.85|5614|615.86|0.14|
|Member is Male|22161|0.49|5593|0.50|5482|0.49|0.91|5472|0.50|0.96|5614|0.49|0.62|
|Age of caregiver|3801|30.65|965|30.39|946|30.60|0.65|925|30.79|0.35|965|30.82|0.32|
|Age of caregiver Squared|3801|1026.28|965|1018.55|946|1022.03|0.92|925|1030.06|0.74|965|1034.55|0.65|
|Caregiver is male|3801|0.01|965|0.01|946|0.01|0.09|925|0.02|0.45|965|0.01|0.31|

38
||Ov|erall|Co|ntrol||HWWS|||TSSM|||HWWS+TSS|M|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Variable|N|Mean|N|Mean|N|Mean|p-value|N|Mean|p-value|N|Mean|p-value|
|_HH Income Sources at Baseline_||||||||||||||
|Most Important income: Employment (Paid Employee)|3619|0.03|919|0.03|900|0.03|0.57|880|0.04|0.15|920|0.02|0.32|
|Most Important income: Employment (Self-Empoyment with<br>employees)|3619|0.06|919|0.06|900|0.06|0.91|880|0.05|0.55|920|0.06|0.85|
|Most Important income: Not-employed (Remmitances)|3619|0.00|919|0.00|900|0.00|0.55|880|0.00|0.98|920|0.00|0.31|
|Most Important income: Self Employed Agricultural|3619|0.74|919|0.74|900|0.72|0.68|880|0.75|0.72|920|0.76|0.64|
|_Latrine Type at Baseline_||||||||||||||
|Flush/pour latrine|3618|0.03|919|0.02|900|0.05|0.05|879|0.02|0.82|920|0.04|0.34|
|No toilet facilities (open defecation)|3618|0.12|919|0.17|900|0.13|0.48|879|0.06|**0.01**|920|0.09|0.09|
|Pit latrine with slab or VIP|3618|0.84|919|0.80|900|0.81|0.84|879|0.91|**0.01**|920|0.86|0.23|
|_Axcces to Water_||||||||||||||
|Main source of drinking water comes from piped water|3619|0.14|919|0.08|900|0.22|**0.01**|880|0.12|0.23|920|0.14|0.12|
|Main source of drinking water comes from a well or borehole|3619|0.32|919|0.37|900|0.26|0.06|880|0.31|0.39|920|0.34|0.62|
|Main source of drinking water comes from surface water|3619|0.40|919|0.42|900|0.38|0.54|880|0.38|0.54|920|0.42|0.98|
|Is the water source covered|3127|0.22|849|0.27|706|0.25|0.88|777|0.19|0.18|795|0.16|0.08|
|Number of person trips HH makes to fetch water per day|3477|2.77|886|2.75|838|2.66|0.65|857|2.85|0.59|896|2.81|0.73|
|Number of times out of the last 10 attempts water has not been<br>available|3617|0.30|919|0.25|899|0.33|0.39|880|0.27|0.81|919|0.35|0.28|
|HH stores water|3619|0.93|919|0.91|900|0.94|0.18|880|0.95|0.12|920|0.93|0.55|
|HH treats their water|3619|0.40|919|0.37|900|0.39|0.80|880|0.41|0.46|920|0.44|0.22|
|_Assets owned by HH at Baseline_||||||||||||||
|Wealth index at Baseline|3619|0.00|919|0.09|900|0.13|0.13|880|-0.34|0.35|920|0.10|0.60|
|Household listens to the radio regularly|3619|0.61|919|0.55|900|0.60|0.30|880|0.64|0.07|920|0.64|**0.04**|
|Total number of assets|3619|44.18|919|44.44|900|43.95|**0.03**|880|44.09|0.17|920|44.22|0.35|
|Another House|3615|0.15|918|0.14|900|0.16|0.36|878|0.17|0.19|919|0.14|0.86|
|Radio/CD/Cassette Player|3616|0.68|919|0.65|900|0.67|0.55|878|0.71|0.07|919|0.67|0.51|
|TV|3617|0.03|919|0.03|900|0.04|0.49|878|0.03|0.99|920|0.02|0.46|
|Bicycle|3617|0.63|919|0.62|900|0.60|0.59|878|0.62|0.87|920|0.67|0.24|
|Motorcycle|3616|0.05|919|0.04|900|0.07|0.13|878|0.04|0.94|919|0.06|0.25|

39
||Ov|erall|Co|ntrol||HWWS|||TSSM|||HWWS+TSS|M|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Variable|N|Mean|N|Mean|N|Mean|p-value|N|Mean|p-value|N|Mean|p-value|
|_Assets owned by HH at Baseline (cont)_||||||||||||||
|Car|3617|0.01|919|0.00|900|0.01|0.09|878|0.00|0.73|920|0.01|0.51|
|Elctric/Gas Stove|3617|0.00|919|0.00|900|0.01|0.70|878|0.00|0.95|920|0.00|0.17|
|Other Stove|3617|0.25|919|0.20|900|0.30|**0.01**|878|0.26|0.06|920|0.25|0.13|
|Refridgerator|3617|0.01|919|0.01|900|0.01|0.31|878|0.01|0.79|920|0.02|0.70|
|Mattress|3617|0.72|919|0.66|900|0.75|0.05|878|0.72|0.23|920|0.73|0.14|
|Sewing Machine|3616|0.05|918|0.04|900|0.06|0.14|878|0.05|0.93|920|0.05|0.93|
|Mosquito Net|3617|0.88|919|0.88|900|0.89|0.74|878|0.86|0.43|920|0.87|0.59|
|Mobile Phone|3617|0.48|919|0.45|900|0.51|0.08|878|0.47|0.54|920|0.49|0.27|
|Fixed-line phone|3617|0.00|919|0.00|900|0.00|0.31|878|0.00|0.65|920|0.01|0.18|
|Iron|3616|0.13|919|0.11|899|0.14|0.22|878|0.15|0.10|920|0.12|0.71|
|Bed frame|3617|0.70|919|0.67|900|0.73|0.08|878|0.71|0.29|920|0.69|0.59|
|Jewellery|3616|0.01|919|0.01|899|0.01|0.59|878|0.00|0.16|920|0.01|0.44|
|Land or Field|3616|0.66|919|0.67|900|0.69|0.61|877|0.67|0.94|920|0.63|0.36|
|Agricultural Equipment|3617|0.16|919|0.16|900|0.16|0.90|878|0.15|0.91|920|0.17|0.76|
|Electricity Generator|3617|0.01|919|0.02|900|0.01|0.09|878|0.01|0.06|920|0.01|0.08|
|Solar Panel|3617|0.01|919|0.02|900|0.01|**0.03**|878|0.01|0.47|920|0.01|0.37|
|Sponged Sofa|3617|0.07|919|0.06|900|0.09|0.17|878|0.06|0.87|920|0.06|0.96|
|Sofa (non-sponged)|3617|0.09|919|0.08|900|0.11|0.40|878|0.08|0.89|920|0.09|0.89|
|Fan|3617|0.01|919|0.00|900|0.01|0.39|878|0.00|0.74|920|0.01|0.83|
|Camera|3617|0.00|919|0.00|900|0.00|0.46|878|0.01|0.21|920|0.00|0.70|
|_Number of Animals Owned by HH at Baseline_||||||||||||||
|Total Number of Animals Owned by HH|3619|16.12|919|17.11|900|16.57|0.86|880|15.09|0.42|920|15.68|0.59|
|Cows|3619|2.38|919|3.32|900|2.45|0.52|880|1.66|0.16|920|2.04|0.29|
|Bulls|3619|1.22|919|1.90|900|1.01|0.17|880|0.89|0.10|920|1.09|0.20|
|Donkeys|3619|0.14|919|0.21|900|0.13|0.41|880|0.10|0.20|920|0.12|0.28|
|Goats|3619|3.31|919|3.28|900|3.94|0.43|880|2.77|0.43|920|3.23|0.94|
|Sheep|3619|0.68|919|0.85|900|0.59|0.36|880|0.38|0.07|920|0.87|0.96|
|Pigs|3619|0.30|919|0.30|900|0.26|0.68|880|0.34|0.73|920|0.32|0.85|
|Chickens|3619|7.39|919|6.77|900|7.43|0.40|880|8.22|**0.04**|920|7.18|0.53|
|Ducks|3619|0.46|919|0.27|900|0.53|0.08|880|0.36|0.45|920|0.66|**0.03**|
|Geese|3619|0.00|919|0.00|900|0.01|0.31|880|0.01|0.31|920|0.00|-|
|Rabbits|3619|0.04|919|0.06|900|0.07|0.84|880|0.01|0.15|920|0.01|0.11|
|Guinea Fowls|3619|0.06|919|0.05|900|0.04|0.70|880|0.10|0.44|920|0.06|0.91|
|Other Animals|3619|0.14|919|0.10|900|0.10|0.99|880|0.24|0.41|920|0.11|0.93|

Notes: p-values are based on a simple t-test comparison between control and relevant treatment group with standard errors clustered at the ward level. P-values < 0.05 are in bold 40
# Table 5: Program exposure

|||<br>HW|<br>WS|||<br>TSS|<br>M||
|---|---|---|---|---|---|---|---|---|
|VARIABLES|High<br>(3 channels)|Medium<br>(>= 2 channels)|Low<br>(>= 1 channel)|Number of<br>channels|High<br>(3 channels)|Medium<br>(>= 2 channels)|Low<br>(>= 1 channel)|Number of<br>channels|
||(1)|(2)|(3)|(4)|(5)|(6)|(7)|(8)|
|HWWS (β1)|0.071***|0.212***|0.373***|0.656***|0.068***|0.193***|0.251***|0.512***|
||(0.012)|(0.024)|(0.033)|(0.061)|(0.012)|(0.024)|(0.031)|(0.057)|
|TSSM ( β2)|0.006|0.036*|0.100***|0.142***|0.026**|0.080***|0.141***|0.247***|
||(0.008)|(0.021)|(0.025)|(0.047)|(0.010)|(0.019)|(0.029)|(0.050)|
|HWWS + TSSM (β3)|0.061***|0.254***|0.442***|0.758***|0.103***|0.266***|0.345***|0.714***|
||(0.011)|(0.026)|(0.026)|(0.055)|(0.014)|(0.024)|(0.027)|(0.057)|
|p-values β1= β2|0.000|0.000|0.000|0.000|0.000|0.000|0.002|0.000|
|for F-test β1= β3|0.500|0.180|0.061|0.160|0.030|0.015|0.006|0.004|
|β2=β3|0.000|0.000|0.000|0.000|0.000|0.000|0.000|0.000|
|_Observations_|3,619|3,619|3,619|3,619|3,619|3,619|3,619|3,619|
|_R-squared_|0.071|0.168|0.238|0.245|0.077|0.141|0.186|0.191|
|_Control Mean_|0.001|0.014|0.135|0.150|0.004|0.040|0.224|0.269|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

41
# Table 6: TSSM awareness

|VARIABLES|Aware of a<br>mason in the<br>community|Aware of a CLTS<br>committee in the<br>village|Agrees with statement:<br>Everybody in this community<br>knows somebody that can be paid<br>to build or improve a latrine|
|---|---|---|---|
||(1)|(2)|(3)|
|HWWS (β1)|0.094***|0.060**|0.027|
||(0.032)|(0.023)|(0.037)|
|TSSM ( β2)|0.183***|0.131***|0.081**|
||(0.036)|(0.026)|(0.035)|
|HWWS + TSSM (β3)|0.188***|0.130***|0.069*|
||(0.031)|(0.028)|(0.035)|
|p-values β1= β2|0.020|0.005|0.138|
|for F-test β1= β3|0.004|0.012|0.251|
|β2=β3|0.871|0.972|0.738|
|_Observations_|3,619|3,619|3,619|
|_R-squared_|0.133|0.288|0.072|
|_Control Mean_|0.143|0.119|0.297|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05,

* p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

42
# Table 7: Latrine construction and availability

|VARIABLES|Household<br>constructe|has a [...] latri<br>d within the l|ne that was<br>ast 3years|Household<br>construct|has a [...] latrin<br>ed more than 3|e that was<br> years ago|Household<br>uses a shared<br>|
|---|---|---|---|---|---|---|---|
||any|private|shared|any|private|shared|latrine|
||(1)|(2)|(3)|(4)|(5)|(6)|(7)|
|HWWS (β1)|-0.015|0.026|-0.042**|0.027|0.008|0.019|-0.031|
||(0.035)|(0.030)|(0.020)|(0.024)|(0.017)|(0.013)|(0.030)|
|TSSM ( β2)|0.082**|0.124***|-0.042**|0.035|0.036**|-0.001|-0.092***|
||(0.034)|(0.032)|(0.019)|(0.022)|(0.018)|(0.011)|(0.027)|
|HWWS + TSSM (β3)|0.077**|0.100***|-0.022|-0.009|-0.002|-0.007|-0.076***|
||(0.031)|(0.028)|(0.019)|(0.022)|(0.018)|(0.010)|(0.026)|
|p-values β1= β2|0.006|0.003|0.972|0.731|0.083|0.158|0.028|
|for F-test β1= β3|0.006|0.013|0.302|0.150|0.592|0.052|0.098|
|β2=β3|0.892|0.434|0.267|0.067|0.04|0.602|0.465|
|_Observations_|3,469|3,469|3,469|3,469|3,469|3,469|2,974|
|_R-squared_|0.121|0.108|0.041|0.044|0.039|0.032|0.074|
|_Control Mean_|0.571|0.386|0.185|0.181|0.134|0.046|0.332|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

43
# Table 8: Presence of an improved latrine

|VARIABLES|Improved latr<br>shared f|ine (including<br>acilities)|Improved l<br>defin|atrine (JMP<br>ition)|Improved la<br>defin|trine (strict<br>ition)|
|---|---|---|---|---|---|---|
||Reported<br>(1)|Observed<br>(2)|Reported<br>(3)|Observed<br>(4)|Reported<br>(5)|Observed<br>(6)|
|HWWS (β1)|0.038|0.035|0.049|0.046|0.021|0.028|
||(0.040)|(0.039)|(0.034)|(0.034)|(0.029)|(0.030)|
|TSSM ( β2)|0.124***|0.117***|0.157***|0.151***|0.122***|0.086***|
||(0.039)|(0.039)|(0.034)|(0.035)|(0.029)|(0.028)|
|HWWS + TSSM (β3)|0.074*|0.077**|0.103***|0.106***|0.076***|0.057**|
||(0.038)|(0.038)|(0.031)|(0.031)|(0.029)|(0.026)|
|p-values β1= β2|0.023|0.030|0.001|0.003|0.000|0.076|
|for F-test β1= β3|0.337|0.262|0.091|0.058|0.055|0.339|
|β2=β3|0.176|0.283|0.088|0.161|0.111|0.327|
|_Observations_|3,619|3,619|3,619|3,619|3,619|3,619|
|_R-squared_|0.230|0.214|0.156|0.152|0.151|0.093|
|_Control Mean_|0.761|0.749|0.507|0.497|0.373|0.270|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

Definition of improved latrine is based on JMP standard definition. Broad definition considers only the latrine type, while the strict definition requires that the slab is suitable for separating humans from excreta (there is only one whole in the slab and it is in good repair).

44
Table 9: Household and community open defecation practices

|VARIABLES|HH members usually<br>defecate in<br>|HH members pr<br>defecati|actice open<br>on...|HH is aware of community<br>members practicing OD|Child feces are<br>safely removed<br>|
|---|---|---|---|---|---|
||fields/bushes/rivers|Always/regularly|Sometimes|||
||(1)|(2)|(3)|(4)|(5)|
|HWWS (β1)|-0.032|-0.059|-0.057|-0.052*|0.043|
||(0.040)|(0.041)|(0.044)|(0.029)|(0.036)|
|TSSM ( β2)|-0.120***|-0.098**|-0.062|-0.055*|0.117***|
||(0.039)|(0.041)|(0.043)|(0.029)|(0.034)|
|HWWS + TSSM (β3)|-0.074*|-0.085**|-0.042|-0.066**|0.084**|
||(0.038)|(0.039)|(0.046)|(0.032)|(0.033)|
|p-values β1= β2|0.020|0.342|0.884|0.925|0.036|
|for F-test β1= β3|0.264|0.506|0.735|0.649|0.332|
|β2=β3|0.202|0.746|0.632|0.719|0.332|
|_Observations_|3,616|3,610|3,610|3,592|3,619|
|_R-squared_|0.229|0.135|0.108|0.106|0.186|
|_Control Mean_|0.231|0.299|0.513|0.839|0.716|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

45
Table 10: Caregiver handwashing knowledge and availability of handwashing material

|VARIABLES|Knows when to<br>wash hands<br>(index)<br>(1)|Knows best<br>method to<br>wash hands<br>(2)|Washed hands<br>with soap in<br>last 24 hours<br>(3)|HH soap<br>expenditure in<br>last month (TZS)<br>(4)|HH has a<br>handwashing<br>device<br>(5)|HH has a<br>handwashing<br>station with soap<br>(6)|HH has a fixed<br>handwashing<br>device<br>(7)|Handwashing<br>device within<br>6m of toilet<br>(8)|
|---|---|---|---|---|---|---|---|---|
|HWWS (β1)|0.045**|0.021|0.003|144.695|-0.015|-0.013|0.017**|0.012|
||(0.018)|(0.019)|(0.021)|(116.570)|(0.039)|(0.017)|(0.007)|(0.017)|
|TSSM ( β2)|0.007|0.053**|0.018|269.014**|0.025|-0.030*|-0.001|0.024|
||(0.017)|(0.022)|(0.020)|(120.058)|(0.040)|(0.018)|(0.006)|(0.018)|
|HWWS + TSSM (β3)|0.040**|0.057***|0.020|212.111*|-0.004|-0.018|0.028***|0.063***|
||(0.017)|(0.021)|(0.021)|(122.888)|(0.039)|(0.016)|(0.008)|(0.020)|
|p-values β1= β2|0.031|0.089|0.462|0.294|0.285|0.317|0.028|0.509|
|for F-test β1= β3|0.776|0.054|0.440|0.565|0.776|0.734|0.259|0.013|
|β2=β3|0.049|0.844|0.953|0.650|0.439|0.440|0.001|0.075|
|_Observations_|3,614|3,614|3,599|3,453|3,419|3,295|3,419|2,800|
|_R-squared_|0.072|0.051|0.059|0.050|0.352|0.149|0.040|0.105|
|_Control Mean_|0.302|0.822|0.823|4131.177|0.484|0.080|0.012|0.037|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

46
# Table 11: Caregiver handwashing practices and cleanliness

||HWWS after|fecal contact|HWWS before|handlingfood|Anyexposure eve|nt is accompanied by|
|---|---|---|---|---|---|---|
|VARIABLES|Observed|Reported|Observed|Reported|water only|soap and water|
||(1)|(2)|(3)|(4)|(5)|(6)|
|HWWS (β1)|-0.028|0.042|0.016*|0.077***|0.011|0.006|
||(0.030)|(0.033)|(0.010)|(0.020)|(0.018)|(0.009)|
|TSSM ( β2)|-0.056*|0.033|0.009|-0.023|-0.005|-0.010|
||(0.031)|(0.029)|(0.008)|(0.017)|(0.020)|(0.008)|
|HWWS + TSSM (β3)|0.003|0.025|0.016*|0.022|0.017|0.011|
||(0.029)|(0.033)|(0.008)|(0.019)|(0.020)|(0.008)|
|p-values β1= β2|0.297|0.787|0.490|0.000|0.369|0.062|
|for F-test β1= β3|0.224|0.640|0.976|0.010|0.741|0.614|
|β2=β3|0.031|0.813|0.456|0.014|0.275|0.014|
|_Observations_|961|3,307|2,238|3,307|4,126|4,126|
|_R-squared_|0.074|0.106|0.034|0.119|0.035|0.027|
|_Control Mean_|0.127|0.474|0.013|0.150|0.273|0.038|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects.

47
# Table 12: General hygiene

|VARIABLES|Caregiver hand<br>cleanliness index|Child cleanliness<br>index|Feces observed<br>in house|Smell of feces<br>in dwelling|Garbage is visible<br>in dwelling|Food is<br>covered|HH has ever<br>cleaned latrine|Flies visible<br>around latrine|Feces are visible<br>outside the latrine|
|---|---|---|---|---|---|---|---|---|---|
||(1)|(2)|(3)|(4)|(5)|(6)|(7)|(8)|(9)|
|HWWS (β1)|0.403**|0.077**|-0.000|-0.001|-0.037|0.111***|0.077***|-0.031|-0.007|
||(0.187)|(0.030)|(0.017)|(0.020)|(0.031)|(0.026)|(0.022)|(0.036)|(0.022)|
|TSSM ( β2)|0.037|0.025|0.007|0.002|0.035|0.089***|0.015|-0.018|0.014|
||(0.181)|(0.028)|(0.016)|(0.019)|(0.032)|(0.027)|(0.023)|(0.035)|(0.021)|
|HWWS + TSSM (β3)|0.455**|0.069**|0.008|0.011|-0.037|0.068**|0.072***|0.019|-0.043**|
||(0.179)|(0.030)|(0.018)|(0.021)|(0.031)|(0.029)|(0.024)|(0.037)|(0.021)|
|p-values β1= β2|0.020|0.061|0.602|0.826|0.013|0.398|0.005|0.673|0.341|
|for F-test β1= β3|0.740|0.790|0.617|0.504|0.993|0.124|0.831|0.162|0.115|
|β2=β3|0.008|0.118|0.951|0.618|0.015|0.473|0.017|0.280|0.009|
|_Observations_|3,606|5,585|3,583|3,601|3,524|2,780|2,921|2,974|2,896|
|_R-squared_|0.091|0.210|0.063|0.061|0.045|0.049|0.094|0.087|0.055|
|_Control Mean_|6.765|0.566|0.089|0.124|0.383|0.283|0.800|0.537|0.222|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects. Column (2) also includes child age (month) and gender dummies.

48
# Table 13: Under 5 child health

||Diarrhea||Hemoglobin|Anemic||Anthropo|metric z-scor|es|
|---|---|---|---|---|---|---|---|---|
|VARIABLES|in past 7<br>|Diarrhea in past 14<br>|level (g/L)|(Hb < 110<br>|weight-for-<br>|height-for-|weight-for-<br>|head<br>|
||days|days (Listing Data)||g/L)|age|age|height|circumference|
||(1)|(2)|(3)|(4)|(5)|(6)|(7)|(8)|
|HWWS (β1)|-0.004|-0.013|0.089|0.007|0.015|0.030|-0.006|0.229|
||(0.012)|(0.011)|(0.754)|(0.023)|(0.043)|(0.057)|(0.048)|(0.141)|
|TSSM ( β2)|-0.001|-0.010|-0.772|0.024|-0.044|-0.006|-0.061|0.092|
||(0.012)|(0.012)|(0.713)|(0.022)|(0.035)|(0.059)|(0.048)|(0.129)|
|HWWS + TSSM (β3)|-0.011|-0.021*|-1.652**|0.060**|-0.075**|-0.008|-0.097**|0.227|
||(0.013)|(0.013)|(0.772)|(0.023)|(0.038)|(0.057)|(0.045)|(0.154)|
|p-values β1= β2|0.744|0.813|0.208|0.398|0.137|0.515|0.247|0.263|
|for F-test β1= β3|0.594|0.428|0.023|0.020|0.039|0.476|0.050|0.991|
|β2=β3|0.399|0.360|0.214|0.091|0.396|0.961|0.445|0.351|
|_Observations_|5,768|34,045|5,203|5,203|5,203|5,208|5,202|5,208|
|_R-squared_|0.053|0.051|0.194|0.159|0.062|0.084|0.064|0.223|
|_Control Mean_|0.086|0.168|111.441|0.414|-1.033|-1.946|0.055|-0.511|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects, child gender and age (month) dummies. Column (1) reports on the symptom-based diarrhea measure capured in the household survey. Column (2) reports on direct diarrhea reports captured in the listing survey.

49
# Table 14: Health - age subgroups

||(1)|(2)|(3)|(4)|(5)|(6)|(7)|(8)|(9)|(10)|
|---|---|---|---|---|---|---|---|---|---|---|
||Diarrhea|(14 days)|Hemoglobi|n level(g/L)|Weight-|for-age|Height-|for-age|Head circumfe|rence-for-age|
|VARIABLES|AGE 0-2|AGE 3-4|AGE 0-2|AGE 3-4|AGE 0-2|AGE 3-4|AGE 0-2|AGE 3-4|AGE 0-2|AGE 3-4|
|HWWS (β1)|-0.012|-0.014|-0.306|0.951|0.026|-0.010|0.039|0.001|0.281*|0.151|
||(0.354)|(0.161)|(0.689)|(0.349)|(0.641)|(0.849)|(0.598)|(0.990)|(0.053)|(0.317)|
|TSSM ( β2)|-0.008|-0.015|-0.199|-1.674|-0.057|-0.043|0.009|-0.059|0.106|0.060|
||(0.548)|(0.173)|(0.787)|(0.103)|(0.219)|(0.330)|(0.906)|(0.424)|(0.408)|(0.683)|
|HWWS + TSSM (β3)|-0.026*|-0.013|-2.359***|-0.469|-0.094**|-0.060|0.013|-0.056|0.288*|0.120|
||(0.078)|(0.239)|(0.005)|(0.646)|(0.047)|(0.245)|(0.854)|(0.430)|(0.073)|(0.446)|
|Observations|21,337|12,707|3,239|1,964|3,236|1,967|3,241|1,967|3,241|1,967|
|R-squared|0.043|0.021|0.164|0.149|0.072|0.080|0.109|0.081|0.225|0.229|
|Control Mean:|0.204|0.106|109.038|115.594|-1.019|-1.058|-2.004|-1.847|-0.467|-0.586|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects, child gender and age (month) dummies. Columns (1) and (2) use listing data while columns (3) - (10) use household survey data.

50
Table 15: Robustness checks

|Variables|Specification|HWWS|TS|SM|HWWS|+ TSSM|Observations|R-squared|Control Mean|
|---|---|---|---|---|---|---|---|---|---|
|Diarrhea (past<br>|Original<br>|-0.013 (0.250)|-0.010|(0.373)|-0.021*|(0.096)|34,045|0.051|0.168|
|<br>14 days)<br>(i)|Interviewer dummies<br>|-0.016 (0.115)|-0.008|(0.421)|-0.023**|(0.024)|34,045|0.093|0.168|
||Month dummies|-0.014 (0.210)|-0.007|(0.498)|-0.019*|(0.086)|34,045|0.094|0.168|
||Original|0.030 (0.057)|-0.006|(0.059)|-0.008|(0.057)|5,208|0.084|-1.946|
|Height-for-<br>(ii)|Removing outliers|0.031 (0.054)|0.002|(0.053)|-0.004|(0.052)|5,147|0.085|-1.953|
|age<br>|Interviewer dummies|0.035 (0.054)|-0.008|(0.054)|-0.020|(0.055)|5,208|0.097|-1.946|
||Month dummies|0.034 (0.054)|-0.008|(0.053)|-0.021|(0.052)|5,208|0.100|-1.946|
||Original|0.015 (0.043)|-0.044|(0.035)|-0.075**|(0.038)|5,203|0.062|-1.033|
|Weight-for-<br>(iii)|Removing outliers|0.024 (0.040)|-0.042|(0.033)|-0.073**|(0.036)|5,170|0.063|-1.017|
|age<br>|Interviewer dummies|0.031 (0.042)|-0.050|(0.033)|-0.079**|(0.037)|5,203|0.068|-1.033|
||Month dummies|0.040 (0.040)|-0.047|(0.031)|-0.081**|(0.035)|5,203|0.071|-1.033|
|Head|Original|0.229 (0.141)|0.092|(0.129)|0.227|(0.154)|5,208|0.223|-0.511|
|<br>circumference<br>(iv)|Removing outliers<br>-|0.229* (0.123)|0.086|(0.107)|0.181|(0.131)|5,134|0.187|-0.543|
|for-age<br>|Interviewer dummies<br>|0.100 (0.095)|0.075|(0.095)|0.222**|(0.107)|5,208|0.331|-0.511|
||Month dummies|0.067 (0.100)|0.041|(0.093)|0.149|(0.106)|5,208|0.343|-0.511|
||Original|0.089 (0.754)|-0.772|(0.713)|-1.652**|(0.772)|5,203|0.194|111.441|
|Hemoglobin<br>(v)|Removing outliers|0.199 (0.714)|-0.453|(0.690)|-1.101|(0.733)|5,162|0.196|111.519|
|level (g/L)<br>|Interviewer dummies|-0.181 (0.796)|-0.916|(0.724)|-1.608**|(0.760)|5,203|0.200|111.441|
||Month dummies|-0.656 (0.803)|-1.340*|(0.723)|-2.217***|(0.785)|5,203|0.206|111.441|
|(vi)<br>Abrasions / b|ruising in past 7 days|0.001 (0.008)|0.001|(0.008)|-0.015*|(0.008)|5,764|0.042|0.044|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects, child gender and age (month) dummies. Row (i) uses listing data; rows (ii) - (vi) use household survey data. For rows (i) - (v) outcomes are subjected to robustness tests. "Original" provides the result presented in the main tables. "Removing outliers" excludes observations that are more than three standard deviations away from the mean. "Interviewer dummies" includes control dummies for all survey interviewers. "Month dummies" specification includes both interviewer and month-of-interview dummies. Row (vi) provides evidence on the falsification test.

51
# Table 16: Mechanism testing: differential mortality rates

||(1)<br>Any children|(2)<br>Number of|(3)<br>Child ae|(4)|(5)|(6)<br>Age|(7)|(8)|
|---|---|---|---|---|---|---|---|---|
|VARIABLES|under 5|children under 5|g|0 - 1|1 - 2|2 - 3|3 - 4|4 - 5|
|HWWS|-0.014|-0.022|0.009|-0.003|0.002|-0.001|-0.000|0.002|
||(0.014)|(0.028)|(0.018)|(0.006)|(0.006)|(0.006)|(0.006)|(0.007)|
|TSSM|0.011|0.020|-0.015|-0.004|0.007|0.001|0.006|-0.010*|
||(0.014)|(0.030)|(0.017)|(0.005)|(0.005)|(0.006)|(0.006)|(0.006)|
|HWWS + TSSM|-0.013|-0.034|0.010|-0.005|0.002|-0.001|0.009|-0.004|
||(0.014)|(0.029)|(0.018)|(0.006)|(0.005)|(0.006)|(0.006)|(0.006)|
|Observations|50,885|50,885|34,092|34,092|34,092|34,092|34,092|34,092|
|R-squared|0.068|0.100|0.003|0.002|0.004|0.004|0.002|0.006|
|Control Mean:|0.444|0.666|1.928|0.205|0.209|0.214|0.196|0.176|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects. All results based on listing data.

52
# Table 17: Mechanism testing: latrine seepage and quality

||(1)|(2)|(3)|(4)|(5)|(6)|(7)|(8)|(9)|
|---|---|---|---|---|---|---|---|---|---|
|VARIABLES|Slab is<br>cleanable|Floor is<br>cleanable|Drophole is<br>only hole|Solid slab|Flooded by<br>water|Strong odor|Feces visible<br>outside pit|Flies always<br>present|Has a squat<br>hole cover in<br>place|
|HWWS|0.026|0.040**|0.026|0.018|0.011|-0.023|-0.008|-0.031|0.005|
||(0.020)|(0.019)|(0.033)|(0.027)|(0.011)|(0.019)|(0.022)|(0.036)|(0.014)|
|TSSM|0.032*|0.037**|-0.025|-0.001|0.009|-0.002|0.013|-0.018|0.052***|
||(0.019)|(0.018)|(0.029)|(0.024)|(0.010)|(0.018)|(0.021)|(0.035)|(0.015)|
|HWWS + TSSM|0.014|0.022|-0.023|0.014|0.005|-0.012|-0.044**|0.019|0.039***|
||(0.020)|(0.021)|(0.030)|(0.024)|(0.007)|(0.020)|(0.021)|(0.037)|(0.014)|
|Observations|2,896|2,896|2,896|2,883|2,887|2,892|2,892|2,974|2,791|
|R-squared|0.196|0.224|0.127|0.269|0.053|0.035|0.055|0.087|0.082|
|Control Mean|0.853|0.863|0.580|0.758|0.013|0.176|0.222|0.537|0.038|

Notes: Robust standard errors in parentheses clustered at the ward level.*** p<0.01, ** p<0.05, * p<0.1. Coefficients estimated using a linear probability model including block fixed effects. Results are conditional on household having a latrine.

53
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