metadata: authors: 0: author: Galiani,Sebastian Franco
1: author: Gertler,Paul J.
2: author: Orsola Vidal,Alexandra
count: Peru
docna: 0: docna: Promoting handwashing behavior in Peru : the
            effect of large-scale mass-media and community level interventions
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Sanitation and Sewerage,Engineering,Reproductive Health,Early Child and Children's Health,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
teratopic: Water Supply and Sanitation,Health, Nutrition and Population,Communities and Human Settlements
abstracts: cdata!: This paper analyzes a randomized
            experiment that uses novel strategies to promote handwashing
            with soap at critical times in Peru. It evaluates a
            large-scale intervention that includes a mass media
            provincial campaign and a district-level community
            component. The analysis finds that the mass media
            intervention alone had no significant effect on exposure to
            the handwashing promotion campaign messages, and therefore
            no effect on handwashing knowledge or handwashing behavior.
            In contrast, the community-level intervention, a more
            comprehensive intervention that included several community
            and school activities in addition to the communications
            campaign, was successful in reaching the target audience
            with handwashing promotion messages and in improving the
            knowledge of the treated population on appropriate
            handwashing behavior. Those improvements translated into
            higher self-reported and observed handwashing with soap at
            critical junctures. However, no significant improvements in
            the health of children under the age of five were observed.
            The results are consistent with earlier literature, which
            indicates that substantively changing behavior to improve
            health is a complex task requiring intensive and more
            personalized interventions.
geo_reg_key: 119228,517191
repnme: repnme: Promoting handwashing behavior in Peru :
            the effect of large-scale mass-media and community level interventions
display_title: Promoting handwashing behavior in
            Peru : the effect of large-scale mass-media and community
            level interventions
listing_relative_url: /research/2012/11/16956626/promoting-handwashing-behavior-peru-effect-large-scale-mass-media-community-level-interventions
topicv3: Sanitation m1326453 2000,Water m1326522 137,Infant and Child Health m1326775 642,Sexual Reproductive, Maternal and Child
            Health m1327262 639,Health m1504661 3480
publishtoextweb_dt: 2012-11-01T00:00:00Z
historic_topic: Water Supply and Sanitation,Health, Nutrition and Population,Communities and Human Settlements
no_of_pages: 75
author_keys: 0: author_key: 634921
1: author_key: 428566
2: author_key: 884814
model_extractions: WPS6257 Policy Research Working Paper 6257 Impact Evaluation Series No. 74

# Promoting Handwashing Behavior in Peru

The Effect of Large-Scale Mass-Media and Community Level Interventions _Sebastian Galiani Paul Gertler Alexandra Orsola-Vidal_ The World Bank Sustainable Development Network Water and Sanitation Program November 2012
Policy Research Working Paper 6257

# **Abstract**

This paper analyzes a randomized experiment that uses novel strategies to promote handwashing with soap at critical times in Peru. It evaluates a large-scale intervention that includes a mass media provincial campaign and a district-level community component. The analysis finds that the mass media intervention alone had no significant effect on exposure to the handwashing promotion campaign messages, and therefore no effect on handwashing knowledge or handwashing behavior. In contrast, the community-level intervention, a more comprehensive intervention that included several community and school activities in addition to the communications campaign, was successful in reaching the target audience with handwashing promotion messages and in improving the knowledge of the treated population on appropriate handwashing behavior. Those improvements translated into higher self-reported and observed handwashing with soap at critical junctures. However, no significant improvements in the health of children under the age of five were observed. The results are consistent with earlier literature, which indicates that substantively changing behavior to improve health is a complex task requiring intensive and more personalized interventions.

This paper is a product of the Water and Sanitation Program (WSP), Sustainable Development Network. WSP is a multidonor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. 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. For more information, please email Sebastian Galiani at galiani@econ.umd.edu or Alexandra Orsola-Vidal at aorsolavidal@worldbank.org.

_The Impact Evaluation Series has been established in recognition of the importance of impact evaluation studies for World Bank operations and for development in general. The series serves as a vehicle for the dissemination of findings of those studies. Papers in this series are part of the Bank’s Policy Research Working Paper Series. 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 Behavior in Peru: The Effect of Large-Scale Mass-Media and Community Level Interventions†**

## Sebastian Galiani<sup>1</sup>

## Paul Gertler<sup>2</sup>

## Alexandra Orsola-Vidal<sup>3</sup>

### **JEL codes:** I

**Key words** : hygiene, handwashing, behavior change, randomized evaluation

1 University of Maryland.

2 University of California, Berkeley.

3 World Bank, WSP.

- This trial is registered, number NCT01465204.

Sebastian Galiani is Professor of Economics at the University of Maryland and Alexandra OrsolaVidal is Senior Impact Evaluation Specialist at the World Bank. They served as country investigators for the Peru Global Scaling Up Handwashing Project impact evaluation. This evaluation is part of a cross-country study led by Bertha Briceño (in its early stages led by Jack Molyneaux) together with Alexandra Orsola-Vidal and Claire Chase. Professor Paul Gertler has provided guidance and advice throughout the project. Global advisors also include Sebastian Galiani, Jack Colford, Ben Arnold, Pavani Ram, Lia Fernald, and Patricia Kariger. The authors are grateful to Rocio Florez, the project task team leader in Peru, Glenn Pearce-Oroz, Regional Team Leader for WSP-Latin America and Caribbean region, and to Eduardo Perez, overall task team leader. We also thank Nicolas Ajzenman, Andres Drenik, Laura Jaitman and María Lucía Yanguas for their excellent research assistance. Generous financial support was provided by the Bill and Melinda Gates Foundation.
# **1   Introduction**

Hygiene is essential to the public health mission of reducing the transmission and consequences of disease. The two leading causes of childhood mortality worldwide are diarrheal disease and acute respiratory infections,<sup>4</sup> accounting for two-thirds of the deaths of children under age five.<sup>5</sup> Both of these categories of illness are closely associated with inadequate hygiene. In addition, chronic parasitic infections and diarrhea can lead to anemia, which further hinders children’s development.<sup>6</sup> The provision of safe water and sanitation, and improved hygienic behaviors more generally, has the potential to alleviate the proximate causes of these illnesses and thereby improve health.<sup>7</sup> Medical evidence suggests that the hands are the main transmitters of diarrhea and respiratory infections. As such, they constitute disease vectors carrying respiratory microorganisms and fecal material into the domestic environment of the susceptible child.<sup>8</sup> Health experts recommend handwashing with soap as a critical action in protecting public health because it is a mainstay in infection control.<sup>9</sup> Yet, rates of handwashing with soap at critical times remain low throughout the world, even when both soap and water are available.<sup>10</sup> In a sample of developing countries, the observed rates of handwashing with soap 4 Thirty-five percent of these deaths are due to diarrheal disease and 32 percent are due to acute respiratory infections. It was estimated that 21 percent of deaths in the 42 countries with the highest mortality are due to pneumonia (Black et al. 2003).

5 WHO 2002.

6 Curtis and Cairncross 2003.

7 See, for example, Esrey et al. 1991 and Galiani et al. 2005.

8 Hendley et al. 1973, WHO 2003.

9 Most parasites live and breed in feces and are transmitted to humans when ingested or through the hands. Parasitic infestations pose serious threats to young children and are a cause of child mortality (World Bank 2005). Among those who survive, parasitic infestations are associated with diarrhea and micronutrient malnutrition, which often leads to iron-deficiency anemia, protein-energy malnutrition, and enlargement of the liver and spleen (see, among others, Anderson and May 1991; and Hesham et al. 2004). Currently, anemia, which leads to slow cognitive development, is a widespread global health problem (see, among others, Nokes et al. 1992, and Pollit 1990). In addition, some respiratory tract infections, including the SARS-causing corona virus, are transmitted via the fecal-oral route or simply on hands (World Bank 2005). Hence, adequate handwashing is a primary barrier to the transmission of enteric pathogens, as hands can be cleansed of viruses and bacteria by washing with soap (Curtis and Cairncross 2003), (Faix 1987; Ansari et al. 1989; Luby et al. 2001; Gibson et al. 2002; Montville et al. 2002; Larson et al. 2003).

10 Scott et al. 2003.

2
range between 0 and 34 percent after defecation and 3 and 37 percent after cleaning up a child.<sup>11</sup> This paper focuses on handwashing promotion intervention, which attempts to improve child health by changing this key hygiene-related behavior rather than by implementing large and costly infrastructure investments in water supply or sanitation. In particular, we analyze the Global Scaling Up Handwashing Project in Peru, a large-scale intervention that aims to generate and sustain handwashing with soap behavior at critical junctures among mothers, caregivers, and children up to 12 years old in rural households. By trying to change the underlying factors that determine handwashing behavior (such as knowledge, beliefs, and accessibility of soap and water) among the target population, which is expected to result in improved handwashing behavior, the program tries to disrupt the causal chain that links poor hygiene with parasitic and microbiological disease transmission and thus ill health in children. Thereby, the study focuses on the following relevant outcomes: exposure to the intervention, changes in determinants of handwashing behavior (knowledge, beliefs, and access to/placement of soap and water), handwashing behavior (self-reported and observed), environmental contamination, and child health. To measure these behaviors and outcomes, we combined different quantitative and qualitative data collection techniques, including detailed questionnaires, structured observations, microbiological analysis of samples of children’s stools, capillary blood, and drinking water collected in the field, and anthropometric measures performed by health experts.

The Global Scaling Up Handwashing Project in Peru intervention consisted of two main components:

- a province-level mass media campaign; and

- a more comprehensive district-level community treatment that included, in addition to the media campaign, training of community agents; capacity building of mothers, caregivers, and children; and the inclusion of handwashing promotion as part of primary school curricula.

> 11 World Bank 2005.

3
The project also included supportive activities such as partnership building and policy reform that aimed to create an enabling environment capable of inducing and sustaining appropriate handwashing behavior. This study does not evaluate these enabling environment activities, but focuses exclusively on the effect of the mass media campaign and community treatment.

The results of this evaluation show that the mass media intervention alone was not effective in reaching the targeted population with the handwashing messages and therefore failed to improve knowledge and beliefs of mothers and caregivers regarding appropriate handwashing, or to generate a behavior change that could improve child health. However, the district-level interventions also analyzed in this paper proved to be effective in reaching the targeted audience with handwashing promotional messages. The community-level treated group was 19.4 percent more likely to report having received the intervention messages through at least one communication channel than the control group. Handwashing campaigns and promotional events at the community level and one-to-one activities seemed to have successfully transmitted the importance of handwashing with soap. Not only did the message reach the treated population, but it also improved caregivers’ knowledge about the best way to wash hands by 6 percent **,** and increased the availability of soap and water in the household by 8.4 percent **.** These improvements led to a statistically significant increase in self-reported and observed handwashing with soap before food contact as compared to the control groups. However, this behavior change did not translate into better child health. No significant impact was found on parasite and bacterial prevalence in stools and drinking water (respectively), which is consistent with the fact that there were no treatment effects on diarrhea, nutrition, or anemia.

These results are consistent with previous studies in the literature of randomized handwashing promotion campaigns, which typically find that handwashing does reduce diarrhea in children under five years old, but those campaigns usually require intensive and controlled interventions. For example, Ejemot et al.<sup>12</sup> reviewed 14 randomized trials, concluding that handwashing programs resulted in a 39 percent reduction in diarrhea

> 12 Ejemot et al. 2009.

4
episodes in children residing in institutions in high-income countries and a 32 percent reduction in such episodes in children living in communities in low- or middle-income countries. The authors suggest that the significant reduction is comparable to the effect of providing clean water in low-income areas. However, the community or institutional interventions studied required a high cost of monitoring and implementing and hence these authors (Ejemot et al. (2009)) conclude that larger scale and less demanding pilots should be performed in developing countries. Luby et al.<sup>13</sup> also showed that handwashing with soap reduces the incidence of acute respiratory tract infections, as well diarrhea, as a result of implementing an intensive and small-scale community-level intervention.<sup>14</sup> Others have studied school-level interventions. Bowen et al.<sup>15</sup> evaluated a school program in China, in which 87 Chinese schools were randomized to a handwashing program that included training for teachers, in-class sessions, encouraging handwashing at school, and a pack for the children’s families that included soap; or to an expanded intervention (handwashing program, soap for school sinks, and peer hygiene monitors).<sup>16</sup> They found that 13 Luby et al. 2005.

14Luby et al. (2005) studied the causal impact of handwashing with soap in child health through a randomized control trial in Pakistan. Fieldworkers visited households weekly for a year to encourage handwashing with soap by residents and to record symptoms in all households. The authors found that children younger than 5 in households that received soap and handwashing promotion had a 50 percent lower incidence of pneumonia, and children younger than 15 had a 53 percent lower incidence of diarrhea than the children in control households.

15 Bowen et al. 2007.

16 Bowen et al. (2007) evaluated the Procter & Gamble’s Safeguard promotion program. Teachers presented the program to first-grade children during a single 40-minute classroom session. Children were instructed in handwashing behavior and asked to wash their hands before meals and after using the toilet. The program included a single two-hour training session for each first-grade teacher by Procter & Gamble staff and provision of a teacher’s pack, animated videotape for classroom use, and a take-home pack for each student. The teacher’s pack contained a guidebook outlining five handwashing steps (wet hands, lather fingers, lather palms and backs of hands, rinse, and dry with a clean towel) and basic information about infectious disease transmission. It also contained five posters describing handwashing procedures and five wall charts designed for classroom hygiene competitions. The student take-home pack included a hygiene board game, a parents’ booklet about handwashing, and a 50-gram bar of Safeguard soap. Although no significant differences in symptoms were found among in-class illnesses, absence incidence decreased in 44 percent for the standard intervention and in 42 percent for the extended treatment. The decrease in days absent was statistically significant only for the extended treatment (decrease of 52 percent). Syndrome-specific absence incidence also differed between groups: students in the standard intervention group were less likely than control students to be absent due to fever and students in the expanded intervention group were less likely to be absent due to headaches or stomachaches than the control students.

5
the expanded intervention significantly reduced syndrome-specific absence incidence (absence due to stomachaches or headaches).

To the best of our knowledge, the studies that so far have found handwashing programs to have significant effects on child health have focused on interventions that impose controlled conditions in small populations over short time periods. These studies are akin to efficacy trials in drug development, which evaluate the impact of a specific intervention under ideal conditions. In most published handwashing studies, the participants are visited each week over a period of months. This style of intense promotion can cause important behavior changes that we would not necessarily expect under non-study conditions where interaction with handwashing promoters is less frequent. Thus, although intensive handwashing interventions have proven effective in reducing diarrhea and acute lower respiratory infections (ALRIs), it has not been proven that similar results could be obtained if those interventions were implemented at scale. This paper, however, studies the effectiveness of a national handwashing campaign to learn the impacts of large-scale handwashing interventions in a real-world context.

Thus, this paper is the first to assess the effect of a large-scale handwashing intervention on a wide range of health indicators. Furthermore, to the best of our knowledge, we are also the first to study other intermediate outcomes, such as the campaigns’ effectiveness and behavior change, which provides important insights on the full theoretical causal chain of disease transmission and ill health.<sup>17</sup> The rest of the paper is organized as follows. Section 2 details the program components. In section 3 we explain the experimental design. Section 4 describes relevant issues concerning the data and sampling procedure and presents some descriptive statistics. Section 5 describes the results of the baseline balance checks and provides an analysis of the panel sample attrition. Section 6 describes the methodological framework. In section 7 we show and interpret the main results of the interventions. Section 8 concludes.

> 17See Cattaneo et al. (2009) for another example of a study of the causal path of an intervention on child health. In this case, the authors studied the effect of improving the floor of houses with cement.

6
# **2   Background and Description of the Program**

In response to the preventable threats posed by poor sanitation and hygiene, the Water and Sanitation Program (WSP) launched two large-scale projects in December 2006—the Global Scaling Up Handwashing Project and the Global Scaling Up Rural Sanitation Project—to improve child health and welfare outcomes of rural households around the world. These projects were implemented by local, regional, and national governments, with technical support from WSP.

The Global Scaling Up Handwashing Project implemented in Peru, Vietnam, Tanzania, and Senegal, borrowed from commercial and social marketing to promote better hygiene. Communication campaigns and messages developed for this project were designed and strategically delivered across multiple integrated channels and in various settings in order to “surround” target audiences with handwashing promotion. Formative research conducted during 2007 with mothers and caregivers revealed that soap was not available for handwashing in most households in Peru, that there was a common belief that washing hands with water was sufficient, and that people did not know the critical times to wash hands with soap. In fact, the results of the structured observations in the baseline showed that soap was used in only 16 percent of the events in which it would have been necessary, that 20 percent of people were observed to wash their hands after fecal contact,<sup>18</sup> and that 25 percent of people washed their hands before eating.<sup>19</sup> Thus, the programs studied had sufficient scope to improve the hygiene habits of the treated households. These rates of soap use are lower than the observed rates in more developed peri-urban areas (47 percent after cleaning up a child in Northern England<sup>20</sup> ) and higher than the rates observed in poorer countries (10 percent after cleaning up a child in Nigeria, 3 percent after defecation in Ghana, or 1 percent in after toilet use in urban Burkina Faso<sup>21</sup> ).

> 18Fecal contact includes defecation, toileting of any kind, and cleaning a child who has defecated.

> 19At the baseline, structured observations of handwashing behavior were conducted in Peru as part of this study, in a subsample of 159 households (see Galiani and Orsola-Vidal 2010). 20 Curtis et al. 2003.

> 21 World Bank 2005.

7
In Peru, the Global Scaling Up Handwashing project was a national intervention implemented in a total of approximately 800 districts randomly selected (in 104 provinces). The project’s primary target audience consisted of mothers of reproductive age (15 to 49 years), caregivers of children under five years old, and children up to 12 years old. The project’s main objective was to improve handwashing behavior among the target audience in order to better the health of children under five. Children under five are the most susceptible to serious consequences from diarrhea and respiratory infection. These infections are usually transferred from dirty hands to food or water sources, or by direct contact with the mouth. Diarrheal disease and respiratory infection among children under five can be prevented by their mothers/caregivers washing their hands with soap at critical times, such as before feeding a child, cooking, or eating, and after using the toilet or changing a child.

The intervention comprised two main components that were delivered at different administrative levels: a mass media plus direct consumer contact treatment at province level, and a community treatment at the district level. The activities included under each component of the project are as follows.

# **2.1 Province-Level Intervention: Mass Media plus Direct Consumer Contact Treatment**

A mass media plus direct consumer contact (DCC) communication campaign was implemented at the provincial level. Because research conducted before project implantation revealed that most people did not use soap when washing hands and that many mothers and caregivers thought using soap was not necessary, the communication strategy focused on the issue of nonuse. The campaign emphasized the importance of the availability and use of soap for handwashing, and the need to wash hands with soap immediately before cooking or eating and after fecal contact (going to the bathroom and changing a baby).

The mass media plus DCC campaign targeted mothers, caregivers, and children, and the main communication channel was broadcast radio. Radio spots, lasting between 30 and 50 seconds each, were aired from five to nine times daily during the months of September to December 8
2009, April to June 2010, and August to November 2010.<sup>22</sup> The campaign also included print materials such as posters with reminders of key junctures in which to wash hands with soap, comic books, and brochures featuring a superhero cartoon character _(Super Jaboncin_ ) created especially for the campaign. Additionally, promotional events such as street parades, games, and local theater performances were conducted in public spaces, where _Super Jaboncin_ came to life to promote handwashing and the use of soap. The jingles developed for the radio spots were used as the events’ background music, ensuring that the target audience received the same messages from multiple channels. On average, the events lasted from two to three hours and had audiences of 100 to 1,000 women and children.

# **2.2 District-Level Intervention: Community Treatment**

The community (or community and school) intervention was conducted at the district level and consisted of:

- a mass-media plus DCC campaign;

- training of trainers of community-based agents of change such as teachers, medical professionals, and community leaders;

- capacity building and provision of educational handwashing sessions for mothers, caregivers, and children; and

- handwashing curricula in select primary schools.

With all these activities, the community intervention aimed to achieve an integral and sustainable change through different actors and channels.

The communications campaign included broadcast radio advertisements with the same messages and frequencies described in the province-level treatment, and print materials such as posters with reminders of key junctures in which to wash hands with soap. It also included print materials featuring _Super Jaboncin_ , the superhero cartoon character developed for the campaign. As part of the communications strategy, the community activities were intentionally tied to the handwashing promotional events. The events took place in different

> 22 According to the baseline survey held for this study, 79 percent of the households had a radio, CD, or cassette player (see Appendix 1 for more information on household assets).

9
venues in the district and the audience might have been different each time or some people might have attended several events.

In addition to the communication campaign, the community treatment included handwashing education sessions with groups of mothers, caregivers, and children. During these handwashing sessions, community-based agents, trained for such a purpose, demonstrated how to properly wash hands with soap, explained the critical junctures in which we must wash our hands with soap, and provided information on the extent to which improved handwashing behavior impacts infant health and welfare. The specialists in charge of conducting the handwashing promotional sessions included schoolteachers, health promoters, and local leaders who were trained as part of the community treatment to play a mediating role in influencing mothers’, caregivers’, and children’s handwashing behavior.

In the districts that received the community treatment, a school-level treatment was delivered to the main primary schools in each district. In these schools, handwashing behavior was introduced as part of the school curricula. The activities included designating a place in the classroom for soap, performing regular handwashing practices in groups each day, weekly handwashing promotion classes, and other children’s activities such as singing songs and drawing posters. This school component of the community intervention tried to transmit the handwashing message to households of children attending the treated schools by including handwashing education in their formal studies.

These components were implemented by national, regional, and local governments. The Water and Sanitation Program (WSP) provided technical assistance, but the intervention was mainly conducted by public and private partners who integrated these activities into the governments’ ongoing projects.<sup>23</sup>

> 23The Global Scaling Up Handwashing Project also included additional activities that were not evaluated as part of this study.  These activities involved partnership building between public and private agents, capacity building of government entities, and policy reforms. These activities aimed to create an enabling environment that facilitated and sustained handwashing behavior with soap.  These activities were assessed separately and the results published in a different study (Favin 2011).

10
# **3 Evaluation Study Design**

Estimating the causal relationship between the treatment and the outcomes of interest requires the construction of an accurate counterfactual—that is, a comparison group that shows what would have happened to the treatment group in the absence of the intervention. To account for factors external to the intervention, counterfactuals are created using comparison groups (control) that are equivalent to the treatment group on every dimension (observed and unobserved) but the treatment. Because a good counterfactual approximates what would have happened to the treatment group in the absence of the treatment, any differences in the average outcome measurements of the treatment and control groups following the implementation can be understood as the causal effect of the intervention. The randomization process, by which a random selection of communities receives the treatment and the remaining serve as controls, generates an appropriate counterfactual for the purposes of the impact evaluation.

Thus, to assess the causal impact of each of the project components on a set of relevant variables, we conducted a controlled randomized trial comprising the province-level treatment as well as the district-level intervention, taking into consideration the general community treatment and its school component.

11
# **Figure 1: Design of the Experiment**

<!-- Start of picture text --> Universe:<br>193 Provinces<br>(total of 195 Provinces excl. Pisco and<br>Lima)<br>Randomization<br>80 Provinces<br>Randomization<br>40 Provinces 40 Provinces<br>Randomization Randomization<br>41 Districts 44 Districts<br>40 Districts<br>Control Group for "Mass District Level Intervention :<br>Province Level Media -DCC alone" & Community Treatment<br>Intervention: Community Treatments<br>"Mass Media -DCC<br>alone" Treatment Main Primary School: Main Primary School:<br>Control Group for "School "School Component"<br>Component" treatment<br><!-- End of picture text --> The targeted areas were districts with populations ranging from 1,500 to 100,000 inhabitants. Figure 1 shows the experiment’s design. First, Pisco and Lima were excluded from the 195 Peruvian provinces.<sup>24</sup> From the 193 remaining provinces, 80 provinces were randomly selected, with 40 assigned to a first group and 40 to a second. From the first group of 40 provinces, 40 districts (with between 1,500 and 100,000 inhabitants) were randomly chosen to receive the mass media province-level treatment. From the second group of provinces, 85 districts (with between 1,500 and 100,000 inhabitants) were randomly selected, with 44 randomly assigned to receive the district-level community treatment and the other 41 randomly assigned to serve as control group for the mass media and community treatments.<sup>25</sup> In addition, for the 44 districts that were randomly assigned to the community treatment, the main school in each district received the school

> 24The province of Pisco was excluded because an earthquake had just hit the area. The province of Lima was excluded because most of its districts were too large for this type of intervention (more than 100,000 inhabitants), and its inhabitants were relatively wealthy.

> 25 Note that because every district had the same probability of being selected for the evaluation,  small, poor districts were overrepresented in the sample. This was desired, however, given that the program was targeted toward the poor.

12
treatment. To create a counterfactual for the subgroup of households with children attending the main school in the treated districts, we also chose a subsample clustered around the main schools in the districts of the control group to serve as a control group for the school intervention.

In what follows we assess the impact of the two treatments: mass media and community on a wide range of outcomes and we also study separately the school level component in the community intervention. We will refer to the households employed to explore the community treatment as _community sample_ and to the households used to investigate the . school component of the community treatment as the _school sample_

# **4   Data Collection**

We conducted baseline and follow-up surveys. The baseline survey was conducted from May through August 2008 in a total of 3,576 households. The follow-up took place four months after the project activities ended—from March through June 2011. We located 2,847 of the original households interviewed for the baseline survey during the follow-up round. We replaced the households we could not find with new households that fit the following criteria: the family had lived in the dwelling for at least the two previous years (e.g., when the intervention took place) and had a child under two years of age at the time of the baseline survey.

For the household-level sampling, in each of the 125 districts allocated to treatment and control groups, we randomly selected between 15 and 20 households from a census conducted prior to our baseline survey that listed all households with children under two years of age. From the 44 districts assigned to the community treatment, we randomly selected an additional set of 15 to 20 households with children under two years old and with at least one sibling attending the main treated schools in each district to assess the effect of the school subcomponent of the district-level intervention. To serve as counterfactual for this last group, in each of the 41 districts allocated to the control group, we randomly chose a second set of 15 to 20 households with children under two years old 13
and with at least one sibling attending a school similar to the main treated school in the treatment districts.

Imasen, a local survey firm, conducted data collection together with a local institution specializing in nutrition ( _Instituto de Investigation Nutritional_ ). The surveys were performed by more than a dozen teams, each consisting of a field supervisor, anthropometric and biometric technicians, household enumerators, and an observer for structured observations. All field team members received extensive training and followed standardized protocols supervised by the project’s investigators to ensure accurate and consistent data collection.

# **4.1 Variables of Interest and Measurement**

Data were collected on a wide range of variables and from different sources. First, a comprehensive household survey inquired about dwelling characteristics, household assets, education, income, labor outcomes, water sources, sanitation, and toilet and handwashing facilities, among other relevant variables (see Appendix 1 for the complete list). Also included were questions on exposure to handwashing campaigns, determinants for handwashing behavior—handwashing knowledge, beliefs, and access to and placement of soap and water—and caregiver self-reported handwashing behavior. To complement the handwashing behavior module, structured observations, during which the family’s handwashing behavior within the household was observed for four to five hours, were conducted on another day following the survey. During that period, the interviewer noted in detail any handwashing event involving adults and children during her stay.<sup>26</sup> In addition, to measure environmental contamination, drinking water microbiology samples were collected inside the households at the time of the survey and analyzed in the field using a membrane filtration technique. The samples were analyzed to determine the presence of _Escherichia coli_ and other types of coliforms.

To assess the household situation with regard to children, caregivers were given a detailed questionnaire with questions about the child’s environment, maternal depression, the

> 26 Structured observations were only carried out for the treatment and control samples of the school treatment.

14
relationship between family and school, and child health. We were mostly interested in symptoms directly or indirectly related to poor handwashing habits. We asked about diarrhea and ALRI prevalence in the last 48 hours and in the last week. Both illnesses are mainly transmitted through the hands—that is, the hands constitute disease vectors carrying respiratory microorganisms and fecal material.<sup>27</sup> We also performed anthropometric measurements of children following standard international procedures, because the synergistic relationship between malnutrition and infection is usually exacerbated in diarrheal episodes given that children tend to eat less during episodes and their ability to absorb nutrients is reduced.<sup>28</sup> These measurements helped us detect the children’s nutritional situation.

A more detailed assessment of the presence of intestinal parasitic infestations in children was achieved by the laboratory analysis of children’s stools. Stool samples<sup>29</sup> were also collected during the interviews in duplicates and sent to Lima for parasitical analysis, using quantitative eggs per gram estimates of soil transmitted helminthes, quantified using Kato-Katz microscopy tests. We registered the prevalence of parasites and the parasite count in stool samples of children under five years of age.

Parasitic infestations pose serious threats to young children’s health because the associated diarrhea and micronutrient malnutrition often leads to iron-deficiency anemia.<sup>30</sup> We therefore also measured anemia in children between six months and five years of age. Health specialists analyzed hemoglobin concentrations from the children’s capillary blood using the HemoCue Hb 201 photometer, a portable device that allows for immediate and reliable quantitative results.

> 27 Hendley et al. 1973; WHO 2003.

> 28 WHO 2003.

> 29 Stool samples were collected only for children under five years of age in the treatment and control groups of the school treatment.

> 30 See, for example, Hesham et al. 2004.

15
# **4.2   Descriptive Statistics**

Peru is a middle-income country with an estimated per capita income of US$5,195 in 2010.<sup>31</sup> Peru has a high human development index (HDI) score of 0.725 based on 2011 data (the index for Latin America and the Caribbean is 0.731 and for the world is 0.682).One-third of the population is poor (31.3 percent) and 9.8 percent is extremely poor.<sup>32</sup> The wealthiest region of the country is Lima, Peru’s capital city, which is excluded from this study. The mean years of schooling for adults older than 25 is 8.9 years and is increasing over time. Most of the children attend school (93 percent primary school and 76 percent high school) according to 2010 data.<sup>33</sup> According to the baseline survey, the households analyzed averaged 5.3 members, with 1.4 children under age five.<sup>34</sup> Around one-half of household heads had attained secondary education and most (95 percent) were employed. The average monthly household income per capita was 140 Peruvian nuevos soles (around US$ 54). The population included in the study was poorer on average than the population of Peru, given that poverty is concentrated in the small districts and that we sampled families with at least one child under two years old.<sup>35</sup> Three-quarters of the households had access to improved sources of drinking water, whereas half of the households had improved sanitation. More than 20 percent of all households had no sanitation facilities of any type.

Handwashing with soap behavior was not prevalent among the interviewed households. Although almost all caregivers report having washed their hands with soap at least once during the previous 24 hours, fewer than half confirmed having done so at times of fecal contact (46 percent of caregivers associated handwashing with soap with toilet use and 42 percent with cleaning up children). Self-reported handwashing with soap was higher at times of cooking or food preparation (68 percent), but lower when feeding a child (34 percent). Structured observations on the use of soap were substantially lower than self-reported rates.

> 31 IMF 2011.

> 32 INEI 2012.

> 33 INEI 2012.

> 34 For the complete list of variables analyzed, see Appendix 1.

> 35 Indeed, the average household in the evaluation sample is poorer than the average Peruvian household (see Galiani and Orsola-Vidal 2010).

16
Handwashing with soap was only observed in 16 percent of the events that required it. For instance, handwashing with soap was observed in only 20 percent of fecal contact events, 25 percent of eating events, 6 percent of child feeding events, and 10 percent of food preparation events.<sup>36</sup> In 64 percent of the households, a handwashing facility—a designated place for handwashing—stocked with soap and water was observed within the dwelling or the yard. The higher the income, the closer the handwashing station was to the toilet or kitchen facility. More than half of the caregivers (53 percent) appeared to have clean fingernails and approximately 67 percent had clean hands or finger pads, whereas 75 percent of the children appeared clean at the time of the interview but 47 percent had dirty fingernails. Households with access to improved sanitation and water source presented lower counts of bacteria in their drinking water. When accounting for income levels, there was a declining trend of Escherichia coli (E. coli) counts with increased income<sup>37</sup> .

Parasitological analysis showed that on average, parasites were detected in 12 percent of the stool samples collected from children under two (the most frequent were Giardia and Blastocystis). Prevalence of parasites was lower among households with access to improved sanitation (7 percent) and water (8 percent) than those with unimproved sanitation (18 percent) or unimproved water (25 percent). The lowest prevalence of parasites was found in households with a handwashing station stocked with soap and water (3 percent) and highest in those without (29 percent).

Concerning child health, 10 percent of children under the age of five were reported by their caregivers to have had diarrhea symptoms in the previous 48 hours and 18.4 percent in the past seven days. Prevalence of diarrhea was higher in households with unimproved sanitation (12 percent) and lower for those with improved sanitation (8 percent); however, diarrhea prevalence was not significantly lower in households with access to a handwashing station

> 37 For a subsample of 159 households, we also analyzed samples from sources other than drinking water. Households with access to improved sanitation also presented lower counts of bacteria in hand rinse and on sentinel objects. Water and caregivers’ hand rinse samples from households with a handwashing station with soap and water had lower bacteria counts (see Galiani and Orsola-Vidal 2010).

17
with soap and water nor in households with access to improved water sources, compared to those without access. Diarrhea prevalence appeared to be uncorrelated with income, but it varied noticeably by geographic location. On average, 4 percent of children had presented ALRI symptoms in the previous 48 hours, and 6 percent in the previous seven days. ALRI prevalence increased for children living in households with unimproved sanitation and those with unimproved water sources. As with diarrhea, similar percentages of households had presented ALRI symptoms in the previous seven days, irrespective of whether they had a handwashing station stocked with soap and water. In addition to these, three-quarters of the samples taken from children younger than two years old indicated the presence of anemia (the proportion was slightly lower for households with improved sanitation).

Finally, the average child was breastfed for 12 months, although more than 60 percent of caregivers gave their children instant formula during the first three days of life. Vitamin A was given to 23 percent of the children and iron supplements to 22 percent. On average, children living in dwellings without improved sanitation, an improved water source, or soap and water at a handwashing station tended to have a lower average z-score for each anthropometric measure included in the analysis as well as for child development indicators (including communication, social-personal, and gross motor skills).

# **5   Balance and Attrition**

## **5.1   Baseline Balance**

Random assignment of the study participants to treatment and control groups ensures that in probability the groups will be similar in their observable and unobservable characteristics. In this section we check that the randomization was performed adequately, resulting in comparable groups.

Appendix 1 shows the mean comparison tests<sup>38</sup> across treatment/control groups for an exhaustive set of variables included in the baseline survey. We compare the characteristics

> 38 The standard errors used in those tests were clustered at the district level, allowing the possibility of intradistrict correlation.

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of households allocated to each treatment with the households of the corresponding control groups. We test for differences in a wide range of variables including socioeconomic characteristics, dwelling facilities and materials, household assets, children’s situation (education, health, nutrition, cognitive development, childcare, and the relationship between family and school), and many variables directly or indirectly associated with handwashing habits. We obtained the variables reported through questionnaires, microbiological analysis of samples (drinking water and child stools), anthropometric measurements, and capillary blood sample of children (for anemia).

The province-level mass media treatment and control comparison used more than 242 variables; in 39 (16.1 percent) of them, we rejected the null hypothesis of mean equality at the 10 percent significance level. This proportion is slightly lower for the district-level intervention: for the community treatment sample, 30 of 242 (12.4 percent), and for the school treatment sample, 29 of 251 (11.5 percent) were unbalanced at conventional significance levels.<sup>39</sup> The larger proportion of statistically significant mean differences in the mass media treatment could have been expected given that the randomization was at province level for this intervention, unlike the district-level randomization within the same provinces for the community treatment samples. One would expect to find less significant differences among districts within the same group of provinces than among districts in different provinces.

The differences between treatment and control groups go in either direction without a clear pattern. The only apparent difference is that the control group for the mass media province treatment appears to perform better in terms of improved sanitation than the treatment group. However, the opposite occurs when comparing the school treatment sample.

> 39 The proportion of unbalanced variables is close to the standard of 10 percent usually acceptable in randomized experiments. It is important to note, however, that the variables measured are not independent (probably neither the balanced nor the unbalanced ones).

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# **5.2   Attrition Analysis**

An important concern for any impact evaluation is the fact that participants sometimes drop out of the study before its completion. Our baseline and endline survey records show an overall attrition rate of 20 percent after three years. This rate is in line with the attrition rates found in other similar randomized studies of this type.<sup>40</sup> In addition to the fact that sample size is reduced, when attrition is systematically related to the outcomes under study or to the program itself, it can bias the estimates of the causal effects of the interventions studied. We followed the standard procedures in the impact evaluation literature to address this potential problem.

First, we explored whether the attrition rates differed between the treatment and comparison groups for each of the interventions studied. As Appendix 2 shows, the proportion of households that stayed in each group ranges from 0.72 to 0.84, and we cannot reject the null hypothesis of equal level of attrition in the control and treatment groups at conventional significance levels in any of the samples studied.

The fact that there was no differential attrition in the treatment and comparison groups is consistent with the hypothesis that attrition is ignorable, and it suggests that the estimate of the treatment effects will not be biased unless different types of households dropped out of the sample in the treatment and the comparison groups.<sup>41</sup> For example, if households with healthier children were more likely to drop out when they were assigned to the treatment group, this could bias the estimator of the program effect on health outcomes downward. Fortunately, this does not seem to be the case in our study. Baseline balance was achieved for the entire initial sample in most of the variables (see Appendix1), and in Appendix 2 we can see that baseline balance is also high for a set of variables for the non-attriters’ sample. This implies that those remaining in the sample and the attriters were balanced in terms of observable characteristics.

> 40 For example, Banerjee et al. (2007) find attrition rates of 17 and 18 percent, respectively, in the comparison and treatment groups in Vadodara (India) in the first year when they evaluated _Balsakhi_ education program in India.

> 41 Angrist 1996

20
Me at pTitandites (1)
The results presented throughout the paper are estimates of model (1). The results are robust to two alternative models: dropping all the control variables and dropping only the geographical dummies. In Appendix 3 we present the results for the three models as robustness checks.

# **7   Effects of the Global Project in Peru**

In this section we present the results for both the province-level and district-level interventions. We present the results following the relevant outcomes of the hypothesized causal chain: exposure to handwashing promotion, effects on handwashing determinants (handwashing knowledge and beliefs, and access to and placement of soap and water), handwashing behavior (self-reported and observed handwashing and hand cleanliness), environmental contamination (bacteria prevalence in drinking water), and child health (prevalence of diarrhea, ALRI, anemia, parasites in stools, nutrition, and anthropometric measures).<sup>43</sup> In addition to assessing the impact of the mass media and community interventions on the mentioned outcomes, we are interested in studying the effect of the school handwashing curricula component, which is part of the community intervention, separately. Thus, in Tables 1–5, ”community treatment sample” refers to the sample of households employed to explore the comprehensive community treatment, and ”school component sample” refers to the households sampled to investigate the community treatment’s school component. In the remaining of the paper, we will use _school component_ and _school treatment_ interchangeably.

## **7.1   Exposure to Handwashing Promotion**

The Global Scaling Up Handwashing Project in Peru uses a behavior change approach; therefore, to expect any project impact, the campaign and its messages must reach the target population. Thus, we asked mothers and caregivers whether they had received handwashing

> 43 We do not pursue the study of child development outcomes because the health results suggest that those could not be causally interpreted as a response to the interventions studied.

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promotional messages during the past 12 months, through any of the three channels used by the intervention: radio and printed materials, promotional events, and educational sessions.

As Table 1 illustrates, the province-level mass media plus DCC treatment did not increase the exposure of the treated households to the handwashing promotion message through any of the channels proposed. Thus, starting with this finding, we do not expect to find any other causal effect that could be attributed to the mass media province-level intervention.

The district-level intervention (mass-media plus DCC, and community treatment) was considerably more successful in exposing the target audience to the handwashing with soap message. The random sample exposed to the community-level treatment was the most affected as a result of this intervention, as the proportion of mothers or caregivers that reported having received handwashing messages through at least one (two) of the communications channels was 15.7 percent (33.5 percent) higher in the treatment group than in the control group.<sup>44</sup> We are also interested in assessing whether the messages imparted at schools reached the attending children—even though those children and their mothers/caregivers might also have been exposed to the other community-level activities. Table 1 shows that the school component increased the probability of low exposure to the treatment (that is, receiving the messages through one channel) by 8.9 percent. To compare this result with that of the community treatment, notice that the households in this treatment group have at least one child attending the school. These households are located in districts also affected by the community treatment, but because they are clustered in a certain area (around the main primary school), their probability of receiving the handwashing message through the other promotional activities in the district might be lower than the probability of receiving them for a random household in the district.

> 44 Note, however, that the control group also reports high levels of exposure to similar messages. Although this might partially reflect measurement error, it might also reflect the fact that other, less intensive campaigns could have been implemented elsewhere.

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# **7.2   Treatment Effects on Handwashing Determinants**

Improving handwashing behavior requires changing the factors that motivate that behavior. These factors are known as _handwashing determinants_ , and include knowledge about the best way to wash hands, beliefs about whether soap is needed for effective handwashing, and the availability and placement of soap and water. Caregivers were asked about their knowledge of effective handwashing habits as well as the availability of water or soap in the household. This would constitute the second link—after exposure to information—in understanding whether the project could lead to a behavior change.

Table 2 shows that the mass media plus DCC treatment was ineffective in improving the knowledge of the survey respondents or in increasing the availability of soap and water in households. This result is expected given that respondents did not show a higher exposure to the handwashing promotion campaign. Table 2 also shows that the district-level interventions increased not only the exposure to the treatment, but also the knowledge of mothers and caregivers regarding handwashing practices. For instance, in the treated districts, there was a significant (around 5 percent) increase in the proportion of respondents answering that the best method for washing hands is using water and soap. In addition, 3.3 percent more households in the treated districts knew that inadequate handwashing is the main cause of diarrhea.

It is important to note that the mean of the control group for these knowledge variables is high: 88 percent of the caregivers answered that the best method for washing hands is with water and soap and 94 percent of the interviewees claimed that inadequate handwashing is the main cause of diarrhea. In these variables, we observe a modest gap of 12 and 6 percentage points, respectively, to total knowledge. If we measure the effect of the community intervention in terms of closing the knowledge gap, we can see that the program reduced this gap by as much as 50 percent (the gap on knowledge regarding the best method for washing hands was reduced by 42 percent and the gap about how inadequate handwashing can cause diarrhea was reduced by 50 percent).

Finally, the community treatment increased the availability of water and soap in households by 8.4 percent (among the school component sample). Again, it is worth mentioning that 24
availability of soap and water anywhere in the dwelling is also high in the control group (e.g., 77 percent of the households in the control group for the school component of the community treatment have water and soap somewhere in the dwelling). Thus, the treatment reduced the gap by 28 percent, which constitutes remarkable progress.

# **7.3   Treatment Effects on Handwashing Behavior**

The next step in the causal chain is assessing whether the improvements in handwashing knowledge and the availability of water and soap brought about by the community treatment translated into handwashing behavior changes.

Measuring handwashing behavior is complex. The simplest and most affordable method for measuring handwashing with soap is to ask respondents to self-report their behavior. However, respondents tend to over report their behavior, especially if they know that handwashing with soap is the right thing to do. Ideally, multiple methods should be used to obtain a more reliable rate of true handwashing behavior. This study uses four different measurement methods and proxies that vary in validity, reliability, and cost to obtain accurate rates of handwashing behavior.<sup>45</sup> These measures include observation of handwashing facilities in the households, cleanliness of caregivers’ hands, self-reported handwashing with soap behavior, and direct structured observations of handwashing. Table 3 summaries the results for these four measures.

Observations of handwashing facilities were conducted in all households. The mother or caregiver was asked to identify any place in the household designated for handwashing after fecal contact or before food contact.<sup>46</sup> When the answer was positive, the enumerator noted all the details about the handwashing facility, including the facility type, its distance from the toilet or kitchen, the availability of water and soap, and the type of soap. At baseline, the proportion of households with at least one handwashing facility near the toilet or kitchen was quite high (66 percent). The community treatment increased the share of households with

> 45 Ram 2010

> 46 Fecal contact includes using the toilet and cleaning a child’s bottom; food contact includes food preparation, eating, or feeding a child.

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handwashing facilities by 4.9 percent (9.2 percent for the school component sample), but the increase was not statistically significant at conventional levels of significance. The enumerators also observed the hands of mothers and caregivers and recorded the cleanliness of their nails, palms, and finger pads. These observations were used to create a Hand Cleanliness Index.<sup>47</sup> The district-level intervention had a positive and significant effect on the hand cleanliness of mothers, as respondents in the community treatment group were 3.6 percent more likely to have clean hands than those in the control group.

Self-reported handwashing behavior was measured by asking mothers and caregivers under what circumstances they had washed their hands with soap in the previous 24 hours. Respondents were asked to recall every time they had used soap during handwashing. Analysis of the responses focused on self-reported handwashing with soap behavior during any of the critical junctures. As Table 3 shows, self-reported handwashing with soap behavior improved in the district-level interventions in almost all the critical junctures, but it was statistically significant only in the school treatment. Among the school component sample, 23.6 percent more respondents in the treatment group reported having washed their hands with soap before eating and 27.8 percent more reported having washed with soap before feeding a child, relative to the control group.

As mentioned earlier, self-reported handwashing behavior tends to be over reported, so in order to triangulate the results, the study included structured observations of handwashing in a subsample of 600 households. Direct observations were conducted among the school component and its control group during a 4-to-5-hour period on the day after the main questionnaire was administered. Enumerators in charge of the structured observations received extensive training on being discreet and not revealing that the visit’s main focus was to observe handwashing behavior. The enumerators observed events that should be followed by handwashing and recorded whether the caregiver had actually washed hands, the time of the event, whether water and soap were used, whether hands were dried, and what was used

> 47 The Hand Cleanliness Index comprises the following components: a) Nails: +1 if visibly dirty, +2 if apparently dirty, +3 if clean; b) Palms: +1 if visibly dirty, +2 if apparently dirty, +3 if clean; and c) Fingerpads: +1 if visibly dirty, +2 if apparently dirty, +3 if clean. The index ranges from 3 to 9, with higher scores indicating greater cleanliness.

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for drying. Table 3 summaries the results of these structured observations. As the results show, the district-level intervention had a significant and large effect on observed handwashing in two of the four main critical junctures. In particular, 61 percent more households in the treatment group washed their hands with soap before eating than those in the control groups. Similarly, treated households were 69 percent more likely to wash hands before food preparation than nontreated households. These effects are encouraging with respect to the potential of the community intervention in achieving behavior change.

There is a possible caveat regarding the results of the structured observations, as individuals may have changed their behavior because they were observed. For instance, Clasen et al. show that during a field trial in India where they measured the number of latrine events with a device hidden in the latrine, the presence of a human observer was associated with a statistically significant increase in the number of latrine events (i.e., the users modified their behavior in response to the observer).<sup>48</sup> In the context of this handwashing campaign in Peru, that type of change in behavior would be true for both the control and the treatment group. However, rates of handwashing with soap as measured by structured observations are substantially lower than self-reported rates, so there does not seem to be a high overreaction to the observer. What could still bias our causal estimates is a situation in which the treated group would react differently in the observer’s presence (probably showing better practices given that they received the handwashing message) relative to what they would do in the control group. If this were the case, our results still would confirm that the treated group had received the handwashing messages and knew when to practice handwashing with soap. Nevertheless, structured observations continue to be the gold standard in measuring handwashing behavior, and it provides a more reliable measure of true handwashing practices than self-reported rates. Thus, the results show that the community intervention was successful in achieving behavior change.

For the mass media provincial-level intervention, we found no negative effects, which are not likely to be attributed to the treatment, as its messages did not reach the targeted audience.

> 48 Clasen et al. 2012.

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# **7.4   Treatment Effects on Environmental Contamination**

Medical evidence suggests that the transmission of diarrhea and respiratory infections is mainly through the hands, which constitute disease vectors carrying respiratory microorganisms and fecal material to the domestic environment of the susceptible child. The use of soap reduces germs and bacteria in hands, thus reducing the risk of becoming sick. It is expected that those practicing handwashing with soap at key junctures will have a lower presence of bacteria such as _Escherichia Coli_ or total coliforms on their hands, thereby reducing the risk of contamination when handling, preparing, or serving drinking water at home. Thus, the study collected samples of drinking water<sup>49</sup> from a subsample of 600 households among the school component sample and its control group. These samples were collected during the administration of the questionnaire, and analyzed to detect the presence of _Escherichia Coli_ and total coliforms. Consistent with previous results, the microbiological analysis of drinking water samples summarized in Table 4 shows that the prevalence of _Escherichia Coli_ and of total coliforms was lower in the treated households than in those of the control group, but none of the effects are statistically significant at conventional levels.

# **7.5   Treatment Effects on Child Health**

The last step in the causal chain is to assess whether the positive results found on exposure to the campaign—knowledge of appropriate handwashing practices, access to soap and water, and handwashing with soap behavior—resulted in health improvements. Table 5 summarizes the effects of the treatments in a wide range of indicators of child health and well-being, including symptoms of illness, nutrition, parasite infestations, and anemia. The results show that overall none of the treatments had a significant effect on those variables.

Because the mass media plus DCC provincial-level treatment alone had no effects on previous outcomes, we did not expect to find any impact on child health. If there were significant estimates, they would probably not be causally attributed to the treatment given that it did not reach the target audience (see Table 1). This is the case of a reduction in the prevalence of

> 49 Drinking water is not the water at source, but rather the water that the household drinks directly. Drinking water can be boiled or treated and is usually stored in containers or jars inside the household.

28
ALRI. In the baseline, this variable was not balanced, as households in the control group were performing significantly worse than those in the treatment group. In the follow-up survey, the situation reverted but there are no grounds to think that it was the effect of the program. This suggests that in this specific health dimension the two groups might not be comparable and that respiratory diseases are influenced by regional temporary variability.

For the district-level intervention (community and school component samples), the improvement in knowledge and behavior change do not seem to have resulted in better health for the children. There are no statistically significant differences between the prevalence of diarrhea or ALRI among children in treated households and those not treated. Nor do we observe any important improvement in the anthropometric measurement<sup>50</sup> or anemia indicators. The prevalence of parasites and the parasite counts obtained from the stool samples (of children under 5 years old) are not significantly different in the control and treatment groups. These results are consistent with the fact that the treatments had no effect on diarrhea, micronutrient malnutrition, or anemia, as these health problems are usually related to parasitic infestations.<sup>51</sup>

# **8     Conclusion**

Some simple technologies, such as vaccines and mosquito bed nets, are cheap and effective preventative measures that can save lives at minimal costs.<sup>52</sup> Handwashing with soap at critical times is another of these technologies: soap is generally easy to use, is relatively cheap, and has the potential of substantially improving the living standards of households. Despite these potential benefits, however, only 3 to 34 percent of people in developing countries routinely wash their hands with soap at critical junctures during the day.<sup>53</sup>

> 50The z-scores for the anthropometric measures were calculated discarding the lower and upper 1 percent of the distribution.

> 51 Unfortunately, a disaggregation of the prevalence of different parasites shows extremely large variability, suggesting that making inference at that level of disaggregation could be unreliable. Nevertheless, we report finding large drops in the treatment group in the prevalence of any _Ascaris Lumbricoides_ infections and any _Trichuris Trichuria_ infections, no differences in Hookworm infections, but a significant rise in the treatment group in any other parasites infection.

> 52 Banerjee and Duflo 2011

> 53 World Bank 2005

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Although medical evidence about the benefits of handwashing with soap is clear, changing handwashing behavior is a complex phenomenon related to personal habits that has multiple determinants (economic, cultural, social, etc.).<sup>54</sup> These characteristics of handwashing result in important difficulties in changing and sustaining these hygienic practices. This paper studies a large-scale handwashing promotion intervention that took place in Peru between 2008 and 2010, and that introduced an innovative mix of communication strategies to induce handwashing with soap at critical times. In particular, the study examined the effect of two different treatments—a province-level mass media campaign and a district-level community treatment—on several outcomes: exposure to the program, handwashing determinants, handwashing behavior, environmental contamination, and child health. We combined different quantitative and qualitative data collection techniques to measure these variables, including detailed questionnaires; structured observations; microbiological analysis of samples of child stools, capillary blood, and drinking water collected in the field; and anthropometric measures performed by health experts.

This paper is the first to assess the effect of a large-scale handwashing with soap intervention using such a wide range of indicators. Previous studies in the literature of randomized handwashing experiments focus on intensive (in terms of labor, inputs and/or monitoring) and controlled treatments, showing that they are effective in reducing diarrhea and pneumonia incidence in children.<sup>55</sup> This study, in contrast, examines a significantly less intensive intervention at scale under real-world conditions. In addition, we study a full set of intermediate outcomes, such as the effectiveness of the campaigns and behavior change, in order to better understand the results in the context of the causal path of disease transmission identified in the medical and public health literature. To the best of our knowledge, ours is the first study of handwashing to focus on all components of this causal chain.

The results of this evaluation show that the mass media intervention alone was not effective in reaching the targeted audience with the handwashing message and therefore failed to improve the handwashing knowledge of mothers and caregivers and to generate a behavior

> 54 Chapman 2010

> 55 Luby et al. 2005

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change that could improve child health. The null results are in line with most of the existing evidence on health promotion campaigns, which typically show that they are ineffective in impacting behavior or that they, at best, enhance the knowledge about the promoted topic. (See, for example, Babor et al.’s work on alcohol prevention campaigns<sup>56</sup> ; Madajewicz et al.’s work on arsenic in water in Bangladesh<sup>57</sup> ; Banerjee and Duflo’s work on vaccination campaigns in Zambia<sup>58</sup> ; and Summerbell et al.’s work on obesity prevention campaigns<sup>59</sup> ).

In contrast, the community intervention, which combined the mass media campaign with more intense training and promotional activities delivered at the district level, proved to be more effective in reaching the targeted audience with the handwashing promotion message, significantly increasing the proportion of mothers and caregivers that reported receiving it. The community treated group reported receiving the message at least through one communication channel more than 15 percent more often than the control group. This more comprehensive treatment seemed to have successfully transmitted the key messages related to handwashing with soap. Increased exposure to the campaign and educational sessions translated into observable learning about best handwashing practices. For example, the proportion of mothers and caregivers that responded correctly that the best method for washing hands is using water and soap increased significantly (around 5 percent) as compared to the control group. Considering the generally good levels of knowledge about this among sample households, this 5 percent change means that almost half the remaining gap in 56 Babor et al. 2003 57 Madajewicz et al. 2007. In this paper, the authors also compared two types of information campaigns and found that the more personalized treatment was more effective. People exposed to a media information campaign obtained as much information as those exposed to a door-to-door campaign, but they did not change their behavior regarding checking whether the dwelling where they obtained water was safe and moving to another dwelling if it was not. The authors also studied a personalized campaign that provided information specific to the individual (whether her/his well is safe and which wells in the vicinity are safe), achieving behavior changes.

58 Banerjee and Duflo (2011) review, among others, the case of Zambia in which a big NGO distributed subsidized chlorine tablets widely, and as a result the campaign informed the population (98 percent identified it as a good way to clean drinking water). However, only 10 percent of families use the tablets. In addition, Banerjee et al. (2010) show that immunization campaigns in rural India are more effective when the poor are given small incentives apart from the vaccines (in this case, lentils and metal plates for completed immunization).

59 Summerbell et al. 2007. Two recent Cochrane reviews on childhood obesity (Campbell et al. 2001; Summerbell et al. 2005) find only modest evidence that diet education impacts the BMIs and consumption habits of schoolchildren, especially in the short term.

31
hygiene knowledge (between current levels and full awareness) has been closed. This improvement in knowledge led, in turn, to statistically significant behavior changes in key areas, such as an 8.4 percent increase in the availability of water and soap in the household, hand cleanliness, and observed and caregiver self-reported handwashing behavior before eating, feeding a child, and preparing food. In addition, observed handwashing with soap only increased among the treated households by 61% before eating and by 69% before preparing food, as compared to the control groups. However, these behavior changes did not translate into better child health. Overall, no impact was found on parasite and bacterial prevalence in stools and drinking water (respectively), which is consistent with the fact that there were no effects on diarrhea, micronutrient malnutrition, or anemia.

The results of this study yield important insights for policymakers and practitioners. Although we did not observe treatment effects on health outcomes, the study successfully identified which component of the intervention was more effective in changing handwashing behavior. Handwashing with soap at critical junctures continues to be a preventive measure to improve child health, especially in developing countries with a high incidence of diarrhea. Thus, future efforts should be invested in identifying additional activities, delivery mechanisms, and/or more effective messages in order to ensure significant and sustainable changes in behavior that improve child health.

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35
**Table 1: Effect of the Interventions on Exposure to Handwashing Promotion**

||**Province lev**|**el intervention**||**District leve**|**l intervention**||
|---|---|---|---|---|---|---|
||**Mass me**|**dia treatment**|**Community t**|**reatment sample**|**School co**|**mponent sample**|
||Control mean|Effect of treatment|Control mean|Effect of treatment|Control mean|Effect of treatment|
|**Exposure**<sup>**+**</sup>|||||||
|High exposure to the treatments|0.147|-0.0039|0.147|0.0551|0.2|-0.0275|
|(HW message through three channels)||(0.037)||(0.037)||(0.041)|
|Medium exposure to the treatments|0.432|-0.000929|0.432|0.145***|0.499|0.065|
|(HW message through two channels)||(0.058)||(0.051)<br>[33.5%]||(0.050)|
|Low exposure to the treatments|0.674|-0.065|0.674|0.106**|0.717|0.0637*|
|Clustered standard errors in parentheses; *** p<0.<br>(HW message through one channel)<br>+Channels: mass media (radio and/or printed materi|01 ** p<0.05 * p<0.1<br>als), promotional events and|(0.051)<br>personal training/educatio|nal sessions|(0.045)<br>[15.7%]||(0.042)<br>[8.9%]|

**Table 2: Effect of the Interventions on Handwashing Determinants**

||**Province lev**<br>|**el intervention**<br>||**District leve**<br>|**l intervention**<br>||
|---|---|---|---|---|---|---|
||<br>**Mass me**|<br>**dia treatment**|<br>**Community t**|<br>**reatment sample**|<br>**School co**|<br>**mponent sample**|
||Control mean|Effect of treatment|Control Mean|Effect of treatment|Control Mean|Effect of treatment|
|<br>**Knowledge**|||||||
|Events that require handwashing (summary index)|0.225|0.02<br>(0.019)|0.225|0.009<br>(0.020)|0.222|0.008<br>(0.019)|
|Best method to wash hands|0.879|-0.003<br>(0.021)|0.879|0.0512*<br>(0.027)<br>[5.8%]|0.882|0.044**<br>(0.021)<br>[4.9%]|
|Not washing hands with water and soup is main<br>cause of diarrhea<br>Clustered standard errors in parentheses; *** p<0.01 ** p|0.94<br><0.05 * p<0.1|-0.006<br>(0.014)|0.94|0.0313**<br>(0.012)<br>[3.3%]|0.94|0.011<br>(0.014)|

36
**Table 3: Effect of the Interventions on Behavior Change**

||**Province lev**|**el intervention**||**District leve**|**l intervention**||
|---|---|---|---|---|---|---|
||**Mass med**|**ia treatment**|**Community tr**|**eatment sample**|**School co**|**mponent sample**|
||Control mean|Effect of treatment|Control mean|Effect of treatment|Control mean|Effect of treatment|
|**Handwashing facilities**|||||||
|HW Facilities stocked with water and soap|0.653|-0.019|0.653|0.032|0.67|0.062|
|||(0.057)||(0.048)||(0.043)|
|Water and soap anywhere in the house|0.787|-0.025|0.787|0.0267|0.768|0.065**|
|||(0.040)||(0.037)||(0.032)|
|||||||[8.4%]|
|**HW hand cleanliness**|||||||
|Hands Cleanliness Index|7.527|-0.178|7.527|0.278*|7.403|0.210|
|||(0.166)||(0.161)||(0.151)|
|||||[3.6%]|||
|**Self-Reported handwashing behavior**|||||||
|HW with soap and water previous to eat|0.415|-0.156***<br>(0.040)<br>[-37.5%]|0.415|0.0252<br>(0.046)|0.402|0.095**<br>(0.044)<br>[23.6%]|
|HW with soap and water before food preparation|0.653|-0.007<br>(0.037)|0.653|0.027<br>(0.036)|0.694|-0.042<br>(0.039)|
|HW with soap and water after fecal contact|0.654|-0.084**<br>(0.040)<br>[-12.8%]|0.654|0.0254<br>(0.042)|0.656|0.019<br>(0.043)|
|HW with soap and water before feeding child|0.206|0.037|0.206|0.004|0.194|0.054*|
|||(0.031)||(0.034)||(0.030)|
|||||||[27.8%]|
|**Structured observations**|||||||
|Observed HW with soap and water previous to|||||0.189|0.115**|
|eat|-|-|-|-||(0.049)<br>[60.8%]|
|Observed HW with soap and water before food<br>preparation|-|-|-|-|0.099|0.068*<br>(0.038)<br>[68.6%]|
|Observed HW with soap and water after fecal<br>contact|-|-|-|-|0.342|-0.022<br>(0.056)|
|Observed HW with soap and water before feeding|||||0.076|0.04|
|baby|-|-|-|-|||
|Clustered standard errors in parentheses; *** p<0.01 ** p<0.|05 * p<0.1|||||(0.060)|

**Table 4: Effect of the Interventions on Environmental Contamination**

||**Province level intervention**<br>|**District level**<br>|**intervention**<br>||
|---|---|---|---|---|
||**Mass media treatment**|**Community treatment sample**|**School co**|**mponent sample**|
||Control mean<br>Effect of treatment|Control mean<br>Effect of treatment|Control mean|Effect of treatment|
|**Water analysis**|||||
|Prevalence of E.Coli (Percentage)|-<br>-|-<br>-|0.607|-0.041<br>(0.072)|
|Prevalence of total coliforms (Percentage)|-<br>-|-<br>-|0.793|-0.044<br>(0.062)|

Clustered standard errors in parentheses; *** p<0.01 ** p<0.05 * p<0.1 37
# **Table 5: Effect of the Interventions on Child Health**

||**Province le**|**vel intervention**||**District leve**|**l intervention**||
|---|---|---|---|---|---|---|
||**Mass me**|**dia treatment**|**Community t**|**reatment sample**|**School co**|**mponent sample**|
||Control mean|Effect of treatment|Control mean|Effect of treatment|Control mean|Effect of treatment|
|**Child health**|||||||
|Diarrhea prevalence 48 hours|0.04|0.01<br>(0.013)|0.04|-0.002<br>(0.011)|0.033|0.0012<br>(0.009)|
|Diarrhea prevalence 7 days|0.06|0.011<br>(0.018)|0.06|0.001<br>(0.015)|0.069|-0.005<br>(0.014)|
|ALRI prevalence 48 hours|0.041|-0.039***<br>(0.014)<br>[-96.5%]|0.041|-0.011<br>(0.018)|0.049|-0.0183<br>(0.020)|
|ALRI prevalence 7 days|0.051|-0.047***<br>(0.018)<br>[-89%]|0.051|-0.016<br>(0.022)|0.056|-0.021<br>(0.023)|
|Weight-for-age z-score|-0.69|0.106<br>(0.082)|-0.69|0.000<br>(0.085)|-0.82|0.107<br>(0.087)|
|Length/Height-for-age z-score|-1.453|0.037<br>(0.080)|-1.453|-0.056<br>(0.079)|-1.619|0.083<br>(0.088)|
|Weight-for-length/height z-score|0.203|0.14*|0.203|0.076|0.165|0.106|
|||(0.076)||(0.078)||(0.083)|
|Anemia (Hb < 110 g/L)|0.283|-0.046|0.283|-0.026|0.278|-0.022|
|||(0.033)||(0.033)||(0.029)|
|**Parasites in child stools**|||||||
|Prevalence of parasites|-|-|-|-|0.227|-0.0508<br>(0.046)|
|Parasite count|-|-|-|-|0.303|-0.0851|
|||||||(0.062)|
|Clustered standard errors in parentheses; *** p<|0.01 ** p<0.05 * p<0.1||||||

The z-scores for the anthropometric measures were calculated discarding the lower and upper 1 percent of the distribution.

38
# **Appendix 1: Balance Checks**

## **Individual Variables**

|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatme**|**nt sample**|**District level**|**intervention**|<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|Average number of children<br>under 5 per HH|707|1.459|717|1.398|-0.061|707|1.46|763|1.409|0.051|684|1.493|705|1.435|0.058|
|Average HH size|707|5|717|5.359|**-0.359***|707|5|763|5.05|-0.05|684|6.26|705|6.04|0.22|
|Gender (M ale): HH head|707|0.908|717|0.898|-0.1|707|0.908|763|0.927|-0.019|684|0.905|705|0.929|-0.024|
|Age: HH head|706|35.39|713|37.96|**-2.97*****|706|35.392|762|35.757|-0.365|683|38.269|702|38.47|-0.201|
|Percentage of HH heads that<br>ever attended school|706|0.954|710|0.952|-0.002|706|0.955|763|0.969|-0.014|682|0.959|704|0.97|-0.011|
|Highest educational level<br>achieved: HH head||||||||||||||||
|Primary|672|0.382|674|0.445|-0.063|672|0.382|735|0.41|-0.028|649|0.473|677|0.411|0.062|
|Secondary|672|0.522|674|0.439|**0.083****|672|0.522|735|0.49|0.032|649|0.414|677|0.484|**-0.07***|
|Trade school|672|0|674|0|-|672|0.052|735|0.061|-0.009|649|0.049|677|0.04|0.009|
|University|672|0.052|674|0.051|0.001|672|0.043|735|0.039|0.004|649|0.062|677|0.065|-0.003|
|Gender (M ale): other HH||||||||||||||||
|members|2831|0.37|3126|0.383|-0.013|2831|0.371|3092|0.379|-0.008|3600|0.406|3555|0.416|-0.01|
|Age: other HH members|2827|14.18|3123|15|**-0.82***|2827|14.184|3088|14.776|-0.592|3594|13.609|3549|13.689|-0.08|
|Percentage of other HH<br>members that ever attended||||||||||||||||
|school|1783|0.933|2106|0.935|0.002|1783|0.934|1993|0.963|**-0.029****|2557|0.958|2515|0.957|0.001|
|Highest educational level<br>achieved: other HH members||||||||||||||||
|Kindergarten|1652|0.078|1941|0.062|**-0.016***|1652|0.078|1911|0.061|**0.017***|2434|0.096|2391|0.081|0.015|
|Primary|1652|0.518|1941|0.536|-0.018|1652|0.518|1911|0.507|0.011|2434|0.605|2391|0.622|-0.017|
|Secondary|1652|0.35|1941|0.347|0.003|1652|0.35|1911|0.38|-0.03|2434|0.272|2391|0.269|0.003|
|Trade school|1652|0.039|1941|0.029|0.01|1652|0.039|1911|0.038|0.001|2434|0.014|2391|0.018|-0.004|
|University|1652|0.013|1941|0.024|**0.011****|1652|0.014|1911|0.015|-0.001|2434|0.014|2391|0.01|0.004|
|Percentage of teenagers that<br>spent time on:|||||||||||||||0|
|School|710|0.961|819|0.927|0.034|710|0.962|695|0.965|-0.003|1393|0.933|1375|0.974|-0.041|
|Studying|710|0.973|819|0.958|0.015|710|0.973|695|0.967|0.006|1393|0.953|1375|0.978|-0.025|
|Children care|710|0.728|819|0.71|0.018|711|0.729|695|0.683|0.046|1395|0.72|1375|0.723|-0.003|
|Homework|711|0.713|819|0.752|-0.039|711|0.713|695|0.722|-0.009|1395|0.691|1375|0.699|-0.008|
|Paid work|711|0.016|819|0.019|-0.003|711|0.017|695|0.01|0.007|1395|0.014|1375|0.007|0.007|
|Unpaid work|711|0.091|819|0.188|**-0.097****|711|0.091|695|0.056|0.035|1395|0.08|1375|0.094|-0.014|

39
|||<br>**Mass**<br>**Provinc**|<br>**media treat**<br>**e level inter**|<br>**ment**<br>**vention**|||**Commun**<br>|**ity treatmen**<br>|**t sample**<br>|**District level**|**intervention**<br>|<br>**School**<br>|**component**<br>|**sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contro|l mean|Treatm|ent mean||Treatm|ent mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Percentage of employed HH**||||||||||||||||
|**heads**|707|0.945|714|0.948|-0.003|707|0.945|762|0.963|-0.018|682|0.965|705|0.956|0.009|
|**Last week activity: HH head**||||||||||||||||
|Looking for work|39|0.231|37|0.135|0.096|39|0.231|28|0.286|-0.055|24|0.167|31|0.226|-0.059|
|Taking care of home<br>Not working and not looking|39|0.462|37|0.324|0.138|39|0.462|28|0.357|0.105|24|0.542|31|0.484|0.058|
|for job|39|0.128|37|0.216|-0.088|39|0.128|28|0.25|-0.122|24|0.208|31|0.161|0.047|
|Other|39|0.179|37|0.324|-0.145|39|0.179|28|0.107|0.072|24|0.083|31|0.129|-0.046|
|**Percentage of employed**<br>**other HH members**|1055|0.344|1273|0.346|-0.002|1055|0.344|1289|0.38|-0.036|1151|0.381|1119|0.35|0.031|
|**Last week activity: other HH**<br>**members**||||||||||||||||
|Looking for work|692|0.01|832|0.006|0.004|692|0.01|799|0.005|0.005|713|0.011|727|0.003|**0.008***|
|Studying|692|0.136|832|0.137|-0.001|692|0.136|799|0.14|-0.004|713|0.181|727|0.169|0.012|
|Taking care of home|692|0.803|832|0.802|0.001|692|0.803|799|0.801|0.002|713|0.75|727|0.779|-0.029|
|Not working and not looking||||||||||||||||
|<br>for job|692|0.04|832|0.038|0.002|692|0.04|799|0.038|0.002|713|0.046|727|0.03|0.016|
|Other|692|0.01|832|0.017|-0.007|692|0.01|799|0.016|-0.006|713|0.011|727|0.019|-0.008|
|**Primary work: position**||||||||||||||||
|Self-employed|1290|0.557|1421|0.55|0.007|1290|0.557|1462|0.538|0.019|1325|0.546|1294|0.59|-0.044|
|Employee|1290|0.302|1421|0.265|0.037|1290|0.302|1462|0.325|-0.023|1325|0.303|1294|0.268|0.035|
|Employer or boss|1290|0.003|1421|0.001|0.002|1290|0.003|1462|0.005|-0.002|1325|0.004|1294|0.003|0.001|
|Worker without remuneration|1290|0.123|1421|0.165|-0.042|1290|0.123|1462|0.126|-0.003|1325|0.137|1294|0.134|0.003|
|Day laborer|1290|0.015|1421|0.018|-0.003|1290|0.015|1462|0.005|0.01|1325|0.008|1294|0.005|0.003|
|Other|1290|0.001|1421|0.001|0|1290|0.001|1462|0|0.001|1325|0.002|1294|0|0.002|
|**Monthly salary**|1082|369.64|1148|334.22|34.42|1082|369.64|1245|391.42|-21.78|1101|351.01|1087|336.88|14.13|
|**Hours per week**|1287|42.933|1404|42.551|0.382|1287|42.933|1448|41.823|1.11|1322|40.735|1287|42.045|-1.31|
|**Months worked in last 12**||||||||||||||||
|**months**|1279|9.177|1405|9.731|-0.554|1279|9.177|1446|9.577|-0.4|1307|9.431|1271|9.862|-0.431|

40
# **Household Assets**

|||<br>**Provinc**<br>**Mass**|<br>**e level inter**<br>**media treat**|<br>**vention**<br>**ment**|||**Commun**<br>|**ity treatmen**<br>|**t sample**<br>|**District level i**|**nterventio**<br>|**n**<br>**School**<br>|**component**<br>|**sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Average HHs non labor**||||||||||||||||
|**income**|312|110.37|240|106.01|4.36|312|110.37|205|106.13|4.24|315|111.45|191|129.89|-18.44|
|**HHs Assets**||||||||||||||||
|Radio, CD, cassette|706|0.813|717|0.815|-0.002|706|0.813|762|0.745|**0.068***|682|0.812|705|0.75|**0.062***|
|TV|707|0.532|717|0.513|0.019|707|0.532|762|0.552|-0.02|682|0.595|705|0.609|-0.014|
|VCR|707|0.248|717|0.197|0.051|707|0.248|762|0.241|0.007|682|0.224|705|0.254|-0.03|
|Computer|707|0.02|717|0.015|0.005|707|0.02|762|0.012|0.008|682|0.025|705|0.016|0.009|
|Bicycle|707|0.184|716|0.196|-0.012|707|0.184|762|0.213|-0.029|682|0.217|705|0.24|-0.023|
|M otorbike|707|0.025|717|0.032|-0.007|707|0.025|762|0.039|-0.014|682|0.032|705|0.035|-0.003|
|Car or Tractor|707|0.014|717|0.018|-0.004|707|0.014|762|0.021|-0.007|682|0.015|705|0.007|0.008|
|Refrigerator|707|0.107|717|0.075|0.032|707|0.107|762|0.079|0.028|682|0.087|705|0.118|-0.031|
|Gas Stove|707|0.383|717|0.329|0.054|707|0.383|762|0.419|-0.036|682|0.346|705|0.445|-0.099|
|Other type of stove|706|0.153|717|0.079|**0.074****|706|0.153|762|0.083|**0.07****|682|0.15|705|0.092|**0.058***|
|Blender|707|0.209|717|0.17|0.039|707|0.209|762|0.22|-0.011|682|0.214|705|0.248|-0.034|
|Toaster|707|0.004|717|0.013|-0.009|707|0.004|762|0.007|-0.003|682|0.007|705|0.01|-0.003|
|M icrowave|707|0.011|717|0.007|0.004|707|0.011|762|0.005|0.006|682|0.01|705|0.013|-0.003|
|Washing machine|707|0.006|717|0.003|0.003|707|0.006|762|0.007|-0.001|682|0.009|705|0.011|-0.002|
|Water boiler|707|0.028|717|0.018|0.01|707|0.028|762|0.016|0.012|682|0.018|705|0.026|-0.008|
|Other houses/properties<br>M achinery, equipment for|707|0.109|717|0.035|**0.074***|707|0.109|762|0.171|-0.062|682|0.104|704|0.182|-0.078|
|family business|707|0.023|717|0.031|-0.008|707|0.023|761|0.021|0.002|682|0.015|703|0.02|-0.005|
|**Percentage of HHs having**||||||||||||||||
|**other piece of land**|707|0.475|716|0.369|0.106|707|0.475|763|0.383|0.092|684|0.477|705|0.43|0.047|
|**Percentage of HHs having**||||||||||||||||
|**farm equipment**|707|0.201|716|0.26|-0.059|707|0.201|763|0.215|-0.014|684|0.2|705|0.214|-0.014|
|**Percentage of HHs having**||||||||||||||||
|<br>**animals**|707|0.754|717|0.826|-0.072|707|0.754|763|0.742|0.012|684|0.775|705|0.729|0.046|
|**Average number of**||||||||||||||||
|**livestock owned**|707|2.337|717|2.787|-4.5|707|2.337|763|1.992|0.345|684|2.401|705|2.009|0.392|

41
# **Dwelling Characteristics**

|||<br>**Provinc**<br>**Mass**|<br>**e level inter**<br>**media treat**|<br>**vention**<br>**ment**|||<br>**Commun**|<br>**ity treatmen**|<br>**t sample**|**District level i**|<br>**nterventio**|<br>**n**<br>**School**|<br>**component**|<br>**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Dwelling ownership**||||||||||||||||
|HH member, still paying|707|0.018|716|0.038|-0.02|707|0.018|762|0.026|-0.008|683|0.041|705|0.027|0.014|
|HH member, fully paid|707|0.454|716|0.536|**-0.082***|707|0.454|762|0.459|-0.005|683|0.515|705|0.482|0.033|
|Rented|707|0.13|716|0.084|0.046|707|0.13|762|0.118|0.012|683|0.111|705|0.15|-0.039|
|Family/Friend Loan|707|0.198|716|0.226|-0.028|707|0.198|762|0.277|**-0.079*****|683|0.145|705|0.197|**-0.052***|
|Other|707|0.199|716|0.116|**0.083****|707|0.199|762|0.119|**0.08***|683|0.187|705|0.143|0.044|
|**Type of dwelling**||||||||||||||||
|Detached house|699|0.93|715|0.959|-0.029|699|0.93|755|0.926|0.004|679|0.981|700|0.933|**0.048*****|
|Room in a larger dwelling|699|0.027|715|0.027|**0**|699|0.027|755|0.05|-0.023|679|0.009|700|0.034|**-0.025***|
|Other|699|0.043|715|0.014|**0.029****|699|0.043|755|0.024|0.019|679|0.01|700|0.033|**-0.023***|
|**Dwelling light source**||||||||||||||||
|No lighting|703|0.001|714|0|0.001|703|0.001|761|0.011|**-0.01****|683|0.004|699|0.016|**-0.012***|
|Electricity|703|0.686|714|0.576|0.11|703|0.686|761|0.748|-0.062|683|0.717|699|0.785|-0.068|
|Kerosene|703|0.159|714|0.154|0.005|703|0.159|761|0.059|**0.1****|683|0.127|699|0.059|**0.068***|
|Candles|703|0.137|714|0.227|**-0.090***|703|0.137|761|0.146|-0.009|683|0.138|699|0.112|0.026|
|Other|703|0.017|714|0.043|-0.026|703|0.017|761|0.037|-0.02|683|0.013|699|0.029|-0.016|
|**Dwelling cooking fuel**||||||||||||||||
|Gas|703|0.296|714|0.237|0.023|703|0.296|761|0.293|0.003|683|0.233|699|0.313|-0.08|
|Wood|703|0.587|714|0.718|-0.131|703|0.587|761|0.618|-0.031|683|0.672|699|0.568|0.104|
|Peat/M anure|703|0.09|714|0.001|**0.089****|703|0.09|761|0.045|0.045|683|0.073|699|0.06|0.013|
|Other|703|0.027|714|0.043|-0.016|703|0.027|761|0.045|-0.018|683|0.022|699|0.059|-0.037|
|**Dwelling heat fuel**||||||||||||||||
|Do not heat dwelling|706|0.969|717|0.897|**0.072*****|706|0.969|763|0.971|-0.002|683|0.968|705|0.989|**-0.021****|
|Wood Stove|706|0.02|717|0.095|**-0.07*****|706|0.02|763|0.025|-0.005|683|0.023|705|0.006|**0.017****|
|Other|706|0.011|717|0.008|0.003|706|0.011|763|0.004|0.007|683|0.009|705|0.006|0.003|

42
|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District level**|**intervention**|<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatm|ent mean||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Material of dwelling's**||||||||||||||||
|**walls**||||||||||||||||
|Esteras|699|0.029|715|0.042|-0.013|699|0.029|755|0.032|-0.003|679|0.034|700|0.024|0.01|
|Brick|699|0.094|715|0.062|0.032|699|0.094|755|0.127|-0.033|679|0.09|700|0.123|-0.033|
|Concrete|699|0.054|715|0.014|**0.040****|699|0.054|755|0.057|-0.003|679|0.019|700|0.07|**-0.051****|
|Unbaked brick, adobe|699|0.584|715|0.664|-0.08|699|0.584|755|0.576|0.008|679|0.58|700|0.543|0.037|
|Wood, logs|699|0.103|715|0.088|0.015|699|0.103|755|0.044|0.059|679|0.138|700|0.051|0.087|
|Other|699|0.136|715|0.13|0.006|699|0.136|755|0.164|-0.028|679|0.138|700|0.189|-0.051|
|**Material of dwelling's**||||||||||||||||
|**roof**||||||||||||||||
|Esteras|699|0.04|715|0.056|-0.016|699|0.04|755|0.045|-0.005|679|0.05|700|0.054|-0.004|
|Brick|699|0.023|715|0.038|-0.015|699|0.023|755|0.019|0.004|679|0.029|700|0.024|0.005|
|Concrete|699|0.052|715|0.017|**0.037***|699|0.052|755|0.038|0.014|679|0.024|700|0.053|**-0.029***|
|Wood, logs|699|0.019|715|0.007|0.012|699|0.019|755|0.009|0.01|679|0.012|700|0.02|-0.008|
|Tin, zinc sheeting|699|0.534|715|0.47|0.102|699|0.534|755|0.668|**-0.134***|679|0.571|700|0.636|-0.065|
|Bamboo|699|0.006|715|0.007|-0.001|699|0.006|755|0.028|-0.022|679|0.01|700|0.023|-0.013|
|Other|699|0.328|715|0.406|-0.078|699|0.328|755|0.193|**0.135****|679|0.303|700|0.19|**0.113***|
|**Material of dwelling's**||||||||||||||||
|**floor**||||||||||||||||
|Painted wood|699|0.009|713|0.004|0.005|699|0.009|753|0.009|0|679|0.013|700|0.017|-0.004|
|Concrete|699|0.156|713|0.111|0.045|699|0.156|753|0.159|-0.003|679|0.138|700|0.217|**0.055**|
|Clay, earthen floor|699|0.701|713|0.749|-0.048|699|0.701|753|0.699|0.002|679|0.698|700|0.636|0.062|
|Non polished concrete|699|0.076|713|0.093|-0.017|699|0.076|753|0.098|-0.022|679|0.082|700|0.091|-0.009|
|Other|699|0.059|713|0.043|0.016|699|0.059|753|0.035|0.024|679|0.068|700|0.039|0.029|
|**HH has food not covered**|685|0.225|651|0.257|-0.032|685|0.225|704|0.207|0.018|663|0.27|658|0.24|0.03|
|**HH is clean**|682|0.543|687|0.518|0.025|682|0.543|715|0.593|-0.05|663|0.508|669|0.538|-0.03|
|**HH with garbage in**||||||||||||||||
|**kitchen or house**|686|0.541|677|0.589|-0.048|686|0.541|717|0.488|0.053|668|0.581|666|0.568|0.013|

43
# **Toilet Facilities and Water Sources**

|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District level**|**intervention**|<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Main toilet facility**||||||||||||||||
|No facilities, bush, field|717|0.24|707|0.221|0.019|707|0.221|763|0.239|-0.018|683|0.218|704|0.203|0.015|
|Hanging toilet, latrine<br>|717|0.01|707|0.017|-0.007|707|0.017|763|0.001|0.016|683|0.018|704|0.003|0.015|
|Flush to piped sewer||||||||||||||||
|,<br>system|717|0.132|707|0.226|**-0.094***|707|0.226|763|0.229|-0.003|683|0.217|704|0.339|**-0.122***|
|Flush, to other place<br>Ventilated improved pit|717|0.047|707|0.095|**-0.048****|707|0.095|763|0.101|-0.006|683|0.088|704|0.101|-0.013|
|<br>latrine|717|0.073|707|0.042|0.031|707|0.042|763|0.069|-0.027|683|0.028|704|0.061|-0.033|
|Pit latrine with slab<br>Pit latrine without slab, open|717|0.033|707|0.034|-0.001|707|0.034|763|0.06|-0.026|683|0.023|704|0.044|-0.021|
|<br>pit|717|0.411|707|0.325|0.086|707|0.325|763|0.263|0.062|683|0.381|704|0.217|**0.164*****|
|Other<br>|717|0.053|707|0.04|0.013|707|0.04|763|0.037|0.003|683|0.028|704|0.031|-0.003|
|**% of toilet facilities that**<br>**are public**|544|0.121|548|0.144|-0.023|548|0.144|581|0.129|0.015|532|0.092|553|0.105|-0.013|
|**Location of main toilet**<br>**facility**||||||||||||||||
|Inside household|717|0.156|707|0.202|-0.046|707|0.202|763|0.224|-0.022|684|0.211|705|0.278|-0.067|
|In household yard|717|0.392|707|0.382|0.01|707|0.382|763|0.391|-0.009|684|0.405|705|0.403|0.002|
|Less than 10 mins walk|717|0.34|707|0.291|0.049|707|0.291|763|0.248|0.043|684|0.269|705|0.213|0.056|
|M ore than 10 mins walk|717|0.071|707|0.088|-0.017|707|0.088|763|0.11|-0.022|684|0.076|705|0.077|-0.001|
|No designated area|717|0.038|707|0.035|0.003|707|0.035|763|0.025|0.01|684|0.037|705|0.026|0.011|
|Other<br>|717|0.003|707|0.001|0.002|707|0.001|763|0.003|-0.002|684|0.003|705|0.004|-0.001|
|**Percentage of shared toilet**<br>**facility**<br>|717|0.254|707|0.263|-0.009|707|0.263|763|0.304|-0.041|684|0.23|705|0.271|-0.041|
|**Percentage of safe toilet**<br>**facilities during the night**|715|0.738|707|0.745|-0.007|707|0.745|763|0.773|-0.028|683|0.761|704|0.781|-0.02|
|**Disposal of child**<br>**defecation**||||||||||||||||
|Bushes, ground|717|0.279|707|0.337|-0.058|707|0.337|763|0.266|0.071|684|0.303|705|0.173|**0.13*****|
|Pit, hole in the ground|717|0.1|707|0.092|0.008|707|0.092|763|0.087|0.005|684|0.076|705|0.096|-0.02|
|Open sewer, drain|717|0.025|707|0.048|-0.023|707|0.048|763|0.045|0.003|684|0.047|705|0.065|-0.018|
|Toilet, latrine|717|0.209|707|0.163|0.046|707|0.163|763|0.215|-0.052|684|0.209|705|0.237|-0.028|
|Garbage|717|0.301|707|0.301|0|707|0.301|763|0.307|-0.006|684|0.308|705|0.34|-0.032|
|River|717|0.121|707|0.12|0.001|707|0.12|763|0.092|0.028|684|0.11|705|0.098|0.012|
|Basin, sink|717|0.114|707|0.098|0.016|707|0.098|763|0.06|0.038|684|0.104|705|0.062|0.042|
|Other|717|0.064|707|0.071|-0.007|707|0.071|763|0.041|**0.03***|684|0.064|705|0.045|0.019|

44
|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District le**|**vel interventi**|**on**<br>**School c**|**omponent sa**|**mple**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contro|l mean|Treatm|ent mean||Con|trol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Same sources along**<br>**the year**|707|0.97|717|0.974|-0.004|707|0.97|763|0.988|-0.018|683|0.99|705|0.989|0.001|
|**Source of drinking**<br>**water**||||||||||||||||
|Tanker truck|707|0|717|0.026|**-0.026***|707|0|763|0.004|-0.004|683|0.015|705|0.007|0.008|
|Surface water<br>|707|0.055|717|0.081|-0.026|707|0.055|763|0.031|0.024|683|0.064|705|0.044|0.02|
|Piped water, into<br>dwelling<br>|707|0.223|717|0.233|0.142|707|0.223|763|0.249|-0.026|683|0.228|705|0.25|-0.022|
|Piped water, into yard,<br>plot<br>|707|0.16|717|0.201|-0.041|707|0.16|763|0.232|-0.072|683|0.17|705|0.247|-0.077|
|Piped water, public tap,<br>standpipe|707|0.051|717|0.095|-0.044|707|0.051|763|0.043|0.008|683|0.053|705|0.045|0.008|
|Tube well, wore whole|707|0.024|717|0.013|0.011|707|0.024|763|0.01|0.014|683|0.004|705|0.013|-0.009|
|Dug well, protected|707|0.017|717|0.026|-0.009|707|0.017|763|0.008|0.009|683|0.006|705|0.01|-0.004|
|Dug well, unprotected|707|0.04|717|0.004|0.036|707|0.04|763|0.007|0.033|683|0.026|705|0.009|0.017|
|Spring water, protected<br>i|707|0.262|717|0.121|**0.152***|707|0.262|763|0.257|0.005|683|0.261|705|0.23|0.031|
|Sprng water,<br>unprotected|707|0.041|717|0.077|-0.036|707|0.041|763|0.031|0.01|683|0.038|705|0.023|0.015|
|Other|707|0.127|717|0.123|0.004|707|0.127|763|0.127|0|683|0.135|705|0.123|0.012|
|**Source location**||||||||||||||||
|In own dwelling|436|0.128|406|0.074|0.054|436|0.128|396|0.278|-0.15|411|0.148|355|0.282|-0.134|
|In own yard, plot|436|0.431|406|0.355|0.076|436|0.431|396|0.313|0.118|411|0.372|355|0.287|0.085|
|Elsewhere|436|0.44|406|0.571|-0.131|436|0.44|396|0.409|0.031|411|0.479|355|0.431|0.048|
|**Covered source**||||||||||||||||
|Covered|433|0.607|404|0.597|0.01|433|0.607|393|0.687|-0.08|407|0.582|355|0.645|-0.063|
|Open|433|0372|404|0389|-0017|433|0372|393|0303|0069|407|0388|355|0352|0036|
|Both covered and open|433|.<br>0.021|404|.<br>0.015|.<br>0.006|433|.<br>0.021|393|.<br>0.01|.<br>0.011|407|.<br>0.029|355|.<br>0.003|.<br>0.026|
|**Who mainly collects**||||||||||||||||
|**water from this**||||||||||||||||
|<br>**source**||||||||||||||||
|Adult woman|436|0.846|405|0.847|-0.001|436|0.846|396|0.886|-0.04|411|0.82|355|0.865|-0.045|
|Adult man|436|0.115|405|0.114|0.001|436|0.115|396|0.086|0.029|411|0.117|355|0.101|0.016|
|Girl (< 15 years)|436|0.023|405|0.017|0.006|436|0.023|396|0.015|0.008|411|0.027|355|0.014|0.013|
|Boy (< 15 years)|436|0.014|405|0.02|-0.006|436|0.014|396|0.013|0.001|411|0.022|355|0.02|0.002|
|<br>Other|436|0.002|405|0.002|0|436|0.002|396|0|0.002|411|0.015|355|0|**-0.015***|
|**Satisfied with the**||||||||||||||||
|**quantity**<br>|704|0.724|715|0.734|-0.01|704|0.724|763|0.738|-0.014|681|0.686|702|0.708|-0.022|
|**Does the household**<br>**pay for the water**|706|0.564|716|0.603|-0.039|706|0.564|761|0.662|-0.098|683|0.698|705|0.674|0.024|
|**Fixed, limited**||||||||||||||||
|**quantity obtained for**||||||||||||||||
|**the payment**|389|0.524|428|0.339|**0.185****|389|0.524|495|0.442|0.082|466|0.47|465|0.447|0.023|
|**How water was**||||||||||||||||
|**prepared (last 7 days)**||||||||||||||||
|<br>Boil|649|0.948|603|0.954|-0.006|649|0.948|689|0.972|-0.024|618|0.963|635|0.98|-0.017|
|Chlorine|649|0.034|603|0.06|-0.026|649|0.034|689|0.026|0.008|618|0.026|635|0.02|0.006|
|Let it stand and settle|649|0.032|603|0.06|-0.028|649|0.032|689|0.022|0.01|618|0.026|635|0.022|0.004|
|Other|649|0.015|603|0.015|0|649|0.015|689|0|0.015|618|0.01|635|0.002|0.008|
|Improved water source|707|0.737|717|0.69|0.047|707|0.737|763|0.801|-0.064|683|0.722|705|0.804|-0.082|
|Improved sanitation|707|0.386|717|0.278|**0.108***|707|0.386|763|0.461|-0.075|683|0.335|704|0.544|**-0.209*****|
|Soap and water at HW||||||||||||||||
|<br>station|707|0.588|717|0.562|0.026|707|0.588|763|0.598|-0.01|684|0.639|705|0.603|0.036|
|||||||||45||||||||
# **Handwashing Facilities**

|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District level i**|**nterventio**|**n**<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Wash hands after**<br>**going to toilet**|698|0.986|707|0.993|-0.007|698|0.986|738|0.985|0.001|675|0.994|674|0.987|0.007|
|**Place where usually**<br>**wash hands after going**<br>**to toilet**||||||||||0|||||0|
|Inside toilet facility<br>|683|0.104|685|0.058|**0.046***|683|0.104|718|0.113|-0.009|667|0.1|659|0.118|-0.018|
|Inside kitchen, cooking||||||||||||||||
|<br>place|683|0.105|685|0.067|0.038|683|0.105|718|0.131|-0.026|667|0.112|659|0.082|0.03|
|In ard less than 3 feet||||||||||||||||
|y<br>from toilet<br>|683|0.193|685|0.194|-0.001|683|0.193|718|0.132|**0.061****|667|0.219|659|0.185|0.034|
|Between 10 feet and 3||||||||||||||||
|feet from toilet<br>M ore than 10 feet from|683|0.142|685|0.155|-0.013|683|0.142|718|0.117|0.025|667|0.148|659|0.141|0.007|
|toilet|683|0.335|685|0.352|-0.017|683|0.335|718|0.373|-0.038|667|0.315|659|0.34|-0.025|
|No specific place|683|0.12|685|0.174|-0.054|683|0.12|718|0.134|-0.014|667|0.105|659|0.134|-0.029|
|**Handwashing device,**||||||||||||||||
|**toilet**||||||||||0|||||0|
|Tap, faucet|600|0.643|563|0.584|0.059|600|0.643|620|0.655|-0.012|597|0.631|570|0.695|-0.064|
|Basin, bucket|600|0.335|563|0.352|-0.017|600|0.335|620|0.319|0.016|597|0.337|570|0.295|0.042|
|Other|600|0.022|563|0.064|**-0.042****|600|0.022|620|0.026|-0.004|597|0.032|570|0.011|**0.021****|
|**Water available at**<br>**handwashing station**|599|0.871|561|0.85|0.021|599|0.871|619|0.889|-0.018|594|0.877|570|0.854|0.023|
|**Soaps available**||||||||||0|||||0|
|M ultipurpose bar soap|601|0.095|567|0.254|**-0.159*****|601|0.095|622|0.127|-0.032|597|0.134|571|0.128|0.006|
|Beauty, toilet bar soap|601|0.245|567|0.224|0.021|601|0.245|622|0.241|0.004|597|0.214|571|0.254|-0.04|
|Powder soap, detergent|601|0.486|567|0.347|**0.139****|601|0.486|622|0.471|0.015|597|0.524|571|0.478|0.046|
|No soap observed|601|0.306|567|0.275|0.031|601|0.306|622|0.273|0.033|597|0.295|571|0.282|0.013|
|**Ash, mud at**||||||||||||||||
|<br>**handwashing station**||||||||||0|||||0|
|Ash|595|0.012|553|0.016|-0.004|595|0.012|614|0.01|0.002|590|0.005|566|0.004|0.001|
|M ud|595|0.245|553|0.195|0.05|595|0.245|614|0.238|0.007|590|0.237|566|0.221|0.016|
|Ash and M ud|595|0.034|553|0.045|-0.011|595|0.034|614|0.024|0.01|590|0.049|566|0.037|0.012|
|Neither observed|595|0.709|553|0.743|-0.034|595|0.709|614|0.728|-0.019|590|0.708|566|0.739|-0.031|

46
|||**Provinc**<br>**Mass**|**e level interv**<br>**media treat**|**ention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District level i**|**ntervention**|<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatme|nt mean||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Wash hands before-**<br>**after cooking, feeding**||||||||||||||||
|**a child**|697|0.996|706|0.993|0.003|697|0.996|738|0.996|0|675|0.996|674|0.987|0.009|
|**Place where usually**<br>**wash hands**||||||||||||||||
|Inside toilet facility<br>Inside kitchen, cooking|647|0.028|631|0.014|0.014|647|0.028|700|0.011|0.017|635|0.02|636|0.017|0.003|
|<br>place<br>In yard less than 3 feet|647|0.396|631|0.361|0.035|647|0.396|700|0.434|-0.038|635|0.413|636|0.414|-0.001|
|<br>from kitchen<br>Between 10 feet and 3|647|0.207|631|0.195|0.012|647|0.207|700|0.164|0.043|635|0.17|636|0.165|0.005|
|<br>steps from kitchen<br>|647|0.162|631|0.189|-0.027|647|0.162|700|0.154|0.008|635|0.191|636|0.173|0.018|
|M ore than 10 feet from||||||||||||||||
|kitchen|647|0.124|631|0.127|-0.003|647|0.124|700|0.139|-0.015|635|0.131|636|0.17|-0.039|
|No specific place|647|0.083|631|0.114|-0.031|647|0.083|700|0.097|-0.014|635|0.076|636|0.061|0.015|
|**Handwashing device**||||||||||||||||
|Tap, faucet<br>Container from which|243|0.263|245|0.208|0.055|243|0.263|283|0.314|-0.051|237|0.283|288|0.299|-0.016|
|water is poured|243|0.716|245|0.78|-0.064|243|0.716|283|0.678|0.038|237|0.696|288|0.688|0.008|
|Other|243|0.021|245|0.012|0.009|243|0.021|283|0.007|0.014|237|0.021|288|0.014|0.007|
|**Water available at**<br>**handwashing station**|244|0.75|246|0.785|-0.035|244|0.75|283|0.837|**-0.087***|237|0.819|288|0.792|0.027|
|**Soaps available**||||||||||||||||
|M ultipurpose bar soap|244|0.07|246|0.138|-0.068|244|0.07|283|0.078|-0.008|237|0.097|288|0.049|0.048|
|Beauty, toilet soap<br>Powder or laundry soap,|244|0.107|246|0.081|0.026|244|0.107|283|0.11|-0.003|237|0.114|288|0.101|0.013|
|<br>detergent|244|0.561|246|0.472|0.089|244|0.561|283|0.509|0.052|237|0.612|288|0.573|0.039|
|No soap observed|244|0.352|246|0.341|0.011|244|0.352|283|0.385|-0.033|237|0.287|288|0.365|-0.078|
|**Ash, mud at**<br>**handwashing station**||||||||||||||||
|Ash|240|0.038|241|0.008|0.03|240|0.038|282|0|**0.038***|232|0.013|284|0.007|0.006|
|M ud|240|0.15|241|0.124|0.026|240|0.15|282|0.078|**0.072***|232|0.168|284|0.123|0.045|
|Ash and M ud|240|0.058|241|0.087|-0.029|240|0.058|282|0.025|0.033|232|0.069|284|0.053|0.016|
|Nor Ash nor M ud|240|0.754|241|0.78|-0.026|240|0.754|282|0.897|**-0.143****|232|0.75|284|0.817|-0.067|

47
# **Handwashing Behavior**

|||**Provinc**<br>**Mass**|**e level inter**<br>**media treat**|**vention**<br>**ment**|||**Commun**|**ity treatme**|**nt sample**|**District level i**|**nterventio**|**n**<br>**School**|**componen**|**t sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||Cont|rol mean|Treat|ment mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Percentage of caregivers that washed**<br>**their hands with soap since yesterday**|712|0.997|720|0.999|-0.002|712|0.997|765|0.996|0.001|693|0.999|707|0.994|0.005|
|**Last moment of hand wash since**||||||||||||||||
|**yesterday**||||||||||||||||
|Bathing a child|707|0.255|717|0.195|0.06|707|0.255|759|0.244|0.011|689|0.253|703|0.262|-0.009|
|Washing child's hands|707|0.123|717|0.11|0.013|707|0.123|759|0.083|**0.04***|689|0.094|703|0.083|0.011|
|<br>Cleaning dishes|707|0.41|717|0.459|-0.049|707|0.41|759|0.348|0.062|689|0.437|703|0.331|**0.106*****|
|Doing laundry|707|0.436|717|0.445|-0.009|707|0.436|759|0.44|-0.004|689|0.498|703|0.511|-0.013|
|Because they look dirty|707|0.102|717|0.066|**0.036***|707|0.102|759|0.045|**0.057****|689|0.115|703|0.053|**0.062*****|
|Bathing oneself|707|0.204|717|0.153|0.051|707|0.204|759|0.219|-0.015|689|0.224|703|0.259|-0.035|
|<br>Using toilet|707|0.426|717|0.389|0.037|707|0.426|759|0.397|0.029|689|0.356|703|0.385|-0.029|
|Cleaning baby bottom|707|0.334|717|0.424|**-0.090****|707|0.334|759|0.368|-0.034|689|0.327|703|0.356|-0.029|
|Cleaning latrine|707|0.021|717|0.01|0.011|707|0.021|759|0.008|**0.013***|689|0.015|703|0.024|-0.009|
|Cleaning toilet|707|0.035|717|0.035|0|707|0.035|759|0.022|0.013|689|0.036|703|0.028|0.008|
|Returning home|707|0.123|717|0.13|-0.007|707|0.123|759|0.119|0.004|689|0.129|703|0.134|-0.005|
|<br>Preparing food, cooking|707|0.717|717|0.763|-0.046|707|0.717|759|0.675|0.042|689|0.704|703|0.643|0.061|
|Feeding children|707|0.369|717|0.351|0.018|707|0.369|759|0.278|**0.091*****|689|0.335|703|0.282|0.053|
|Other|707|0.057|717|0.102|**-0.045*****|707|0.057|759|0.075|-0.018|689|0.038|703|0.051|-0.013|
|**Best way to clean hands**||||||||||||||||
|Wipe on cloth|713|0.011|718|0.011|0.989|713|0.011|765|0.013|-0.002|694|0.013|704|0.009|0.004|
|Wash with water alone|713|0.132|718|0.11|0.43|713|0.132|765|0.116|0.016|694|0.134|704|0.111|0.023|
|Wash with soap|713|0.847|718|0.864|0.591|713|0.847|765|0.854|-0.007|694|0.84|704|0.865|-0.025|
|Wash with ash, mud|713|0|718|0.003|0.157|713|0|765|0||694|0.003|704|0|0.003|
|Other|713|0.01|718|0.013|-0.003|713|0.01|765|0.017|-0.007|694|0.01|704|0.016|-0.006|
|**Self-Reported Behavior:**||||||||||||||||
|HW with soap and water before feeding child|710|0.367|719|0.35|0.017|710|0.367|762|0.276|**0.091*****|692|0.333|703|0.281|0.052|
|HW with soap and water before food prep.|710|0.714|719|0.760|-0.046|710|0.714|762|0.671|0.043|692|0.7|703|0.642|0.058|
|HW with soapand water after fecal contact|710|0.615|719|0.668|-0.053|710|0.615|762|0.628|-0.013|692|0.562|703|0.613|-0.051|
|**Caregiver's fingernails are:**||||||||||||||||
|Visible dirty|714|0.284|719|0.303|-0.019|714|0.284|767|0.21|**0.074***|694|0.281|703|0.225|0.056|
|Unclean appearance|714|0.322|719|0.325|-0.003|714|0.322|767|0.286|0.036|694|0.336|703|0.297|0.039|
|Clean|714|0.394|719|0.371|0.023|714|0.394|767|0.505|**-0.111****|694|0.383|703|0.478|**0.098***|
|**Caregiver's palms are:**||||||||||||||||
|Visible dirty|714|0.225|719|0.22|0.005|714|0.225|767|0.154|**0.071***|694|0.225|703|0.137|**0.036***|
|Unclean appearance|714|0.252|719|0.243|0.009|714|0.252|767|0.207|0.045|694|0.272|703|0.272|0|
|<br>Clean|714|0.522|719|0.537|-0.015|714|0.522|767|0.639|**-0.117****|694|0.503|703|0.592|-0.089|
|**Caregiver's finger pads are:**||||||||||||||||
|Visible dirty|714|0.224|719|0.224|0|714|0.224|767|0.147|**0.077***|694|0.22|702|0.14|**0.07****|
|Unclean appearance|714|0.265|719|0.249|-0.016|714|0.265|767|0.21|**0.055***|694|0.277|702|0.255|0.022|
|Clean<br>*p < 10%, ** < 5%, *** < 1%|714|0.511|719|0.527|-0.016|714|0.511|767|0.643|**-0.132****|694|0.503|702|0.605|-0.102|

48
# **Mass Media**

||**Provinc**<br>**Mass**|**e level intervention**<br>**media treatment**||**Commun**|**ity treatment sample**|**District level i**|**ntervention**<br>**School**|**component sample**||
|---|---|---|---|---|---|---|---|---|---|
||Control mean|Treatment mean||Control mean|Treatment mean||Control mean|Treatment mean||
||N<br>Avg.|N<br>Avg.|Difference|N<br>Avg.|N<br>Avg.|Difference|N<br>Avg.|N<br>Avg.|Difference|
|**Recalls of any**<br>**handwashing**||||||||||
|**campaign**|714<br>0.245|722<br>0.253|-0.008|714<br>0.245|769<br>0.224|0.021|694<br>0.272|711<br>0.226|0.046|

# **Family-School Relationship**

|||<br>**Province**<br>**Mass**|<br>**level inter**<br>**media treat**|<br>**vention**<br>**ment**|||**Communi**<br>|**ty treatmen**<br>|**t sample**<br>|**District level i**|**ntervention**<br>|<br>**School**<br>|**component**<br>|**sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatm|ent mean||Contro|l mean|Treatme|nt mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Participation in**<br>**schools activities**||||||||||||||||
|Parents association|296|0.176|389|0.288|**-0.112****|296|0.176|301|0.256|-0.08|688|0.196|702|0.249|-0.053|
|Speeches, conferences|296|0.267|389|0.342|-0.075|296|0.267|301|0.369|**-0.102***|688|0.298|702|0.325|-0.027|
|Kermesses|296|0.139|389|0.111|0.028|296|0.139|301|0.096|0.043|688|0.122|702|0.094|0.028|
|APAFA|296|0.72|389|0.584|**0.136****|296|0.72|301|0.611|**0.109***|688|0.67|702|0.598|0.072|
|Other|296|0.199|389|0.185|0.014|296|0.199|301|0.169|0.03|688|0.161|702|0.175|-0.014|
|Does not participate|296|0.034|389|0.09|**-0.056****|296|0.034|301|0.053|-0.019|688|0.078|702|0.078|0|
|**Percentage of**<br>**caregivers that recall**<br>**any campaign on**<br>**health and hygiene**<br>**promoted by the**||||||||||||||||
|**school**<br>*p < 10%, ** < 5%, *** <|296<br>1%|0.338|389|0.298|0.04|296|0.338|301|0.336|0.002|688|0.39|702|0.392|-0.002|

49
# **Child Development**

||<br>**Provinc**<br>**Mass**|<br>**e level inter**<br>**media treat**|<br>**vention**<br>**ment**||**Commun**<br>|**ity treatmen**<br>|**t sample**<br>|**District level i**|**ntervention**<br>|<br>**School c**<br>|**omponent**<br>|**sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Contro|l mean|Treatm|ent mean||Control mean|Treatm|ent mean||Contro|l mean|Treatm|ent mean||
|N|Avg.|N|Avg.|Difference|N<br>Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|581|0.06|557|0.051|0.009|581<br>0.06|601|-0.014|0.074|533|-0.043|554|-0.057|0.014|
|581|-0.011|556|-0.03|0.818|581<br>-0.011|601|0.001|-0.012|532|0.072|554|-0.027|0.099|
|581|-0.009|554|0.07|0.028|581<br>-0.009|599|-0.052|0.043|533|0.079|553|-0.08|**0.159***|

*p < 10%, ** < 5%, *** < 1%

50
# **Child Care Situation**

51
|||**Province**<br>**Mass**|**level interv**<br>**media treat**|**ention**<br>**ment**|||**Commun**|**ity treatmen**|**t sample**|**District level i**|**ntervention**|<br>**School**|**component**|**sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contro|l mean|Treatme|nt mean||Contro|l mean|Treatm|ent mean||Contr|ol mean|Treatm|ent mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|Average number of times child<br>was left at the charge of<br>another child|732|0.657|735|0.707|-0.05|732|0.657|786|0.641|0.016|717|1.024|729|1.06|-0.036|
|Average number of times was<br>child left alone|734|0.327|735|0.405|-0.078|734|0.327|786|0.314|0.013|717|0.211|729|0.258|-0.047|
|Percentage of children with<br>clean aspect|982|0.667|955|0.625|0.042|982|0.667|1027|0.689|-0.022|980|0.624|955|0.672|-0.048|
|Percentage of children with<br>dirty hands|979|0.501|953|0.518|-0.017|979|0.501|1020|0.429|0.072|976|0.513|951|0.449|0.064|
|Percentage of children with<br>dirty finger nails|973|0.597|948|0.584|0.013|973|0.597|1018|0.476|**0.121****|969|0.608|945|0.525|**0.083***|
|dirty face|981|0.414|955|0.452|-0.038|981|0.414|1029|0.331|**0.083***|979|0.441|955|0.365|0.076|
|clothes|976|0.411|955|0.439|-0.028|976|0.411|1028|0.371|0.04|980|0.476|954|0.399|0.077|
|Percentage of children with<br>dirty clothes|980|0.989|955|0.988|0.001|980|0.989|1030|0.993|-0.004|981|0.989|956|0.985|0.004|
|Pot-belly|979|0.153|944|0.144|0.009|979|0.153|1019|0.106|0.047|977|0.159|951|0.139|0.02|
|Percentage of children wearing<br>shoes (or shoes available)|986|0.853|956|0.844|0.009|986|0.853|1032|0.834|0.019|982|0.869|962|0.823|**0.046***|
|Percentage of children that<br>play with household objects|733|0.673|734|0.58|**0.093****|733|0.673|784|0.626|0.047|718|0.636|729|0.647|-0.011|
|Percentage of children that<br>play with toys|733|0.809|734|0.8|0.009|733|0.809|784|0.8|0.009|718|0.788|729|0.813|-0.025|
|Average number of children's<br>books or pictures|736|0.292|736|0.255|0.037|736|0.292|788|0.208|0.084|718|0.23|730|0.225|0.005|
|attended early education<br>programs|732|0.04|734|0.03|0.01|732|0.04|783|0.041|-0.001|718|0.033|726|0.032|0.001|
|Percentage of adults that read<br>books with child|731|0.274|733|0.225|0.049|731|0.274|784|0.241|0.033|717|0.225|729|0.263|-0.038|
|Percentage of adults that tell<br>stories to the child|732|0.265|731|0.197|**0.068****|732|0.265|784|0.227|0.038|717|0.247|729|0.254|-0.007|
|Percentage of adults that take<br>the child outside the home|733|0.943|734|0.913|0.03|733|0.943|784|0.926|0.017|718|0.911|729|0.918|-0.007|
|Percentage of adults that play||||||||||||||||
|<br>with the child|733|0.868|734|0.869|-0.001|733|0.868|784|0.857|0.011|718|0.831|729|0.842|-0.011|
|Average daily caring time<br>*p < 10Percentage, ** < 5Perc|1028<br>entage, *** <|5.038<br>1Percentage|988|4.924|0.114|1028|5.038|1062|5.704|-0.666|1015|4.858|1001|5.393|-0.535|

52
# **Child Health**

|||<br>**Mass**|<br>**media treat**|<br>**ment**|||**Commun**<br>|**ity treatmen**<br>|**t sample**<br>|||**School**<br>|**component sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||N<br>Contro|Avg.<br>l mean|N<br>Treatme|Avg.<br>nt mean|Difference|N<br>Contro|Avg.<br>l mean|N<br>Treatm|Avg.<br>ent mean|Difference|N<br>Control|Avg.<br>mean|N<br>Avg.<br>Treatment mean|Difference|
|**ALRI inprev. 48 hrs**|1031|0.029|1003|0.103|**-0.07*****|1031|0.029|1074|0.049|-0.02|1017|0.031|1012<br>0.053|-0.022|
|**ALRI inprev. 1 week**|1031|0.04|1003|0.139|**-0.09*****|1031|0.04|1074|0.065|-0.025|1017|0.043|1012<br>0.073|-0.03|
|**Diarrhea inprev. 48 hrs**|1031|0.098|1003|0.082|0.016|1031|0.098|1074|0.101|-0.003|1017|0.077|1012<br>0.084|-0.007|
|**Diarrhea inprev. 1 week**|1031|0.167|1003|0.153|0.014|1031|0.167|1074|0.162|0.005|1017|0.14|1012<br>0.139|0.001|
|**Household w/ lost hours due child**|||||||||||||||
|**illness**|3534|0.014|3832|0.063|**-0.04*****|3534|0.014|3852|0.019|-0.005|4236|0.02|4232<br>0.01|0.01|
|**Anemia (Hb < 110 g/L) - children <2**|605|0.711|652|0.701|0.01|605|0.711|632|0.731|0.503|596|0.711|565<br>0.701|0.01|

*p < 10%, ** < 5%, *** < 1%

# **Anthropometric Measures**

|||<br>**Province**<br>**Mass**|<br>**level intervention**<br>**media treatment**||**Commun**<br>|**ity treatmen**<br>|**t sample**<br>|**District level i**|**ntervention**<br>|<br>**School**<br>|**component**<br>|**sample**<br>||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatment mean||Control mean|Treatm|nt mean||Contro|l mean|Treatm|ent mean||
||N|Avg.|N<br>Avg.|Difference|N<br>Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**BMI-for-age z-score**|709|0.361|719<br>0.463|-0.102|709<br>0.361|769|0.405|-0.044|692|0.455|709|0.471|-0.016|
|**Head circumference-for-age z-**||||||||||||||
|**score**|707|-0.238|714<br>-0.332|0.094|707<br>-0.238|769|-0.31|0.072|690|-0.281|714|-0.261|-0.02|
|**Arm circumference-for-age z-**<br>**score**|635|0.3|631<br>0.397|-0.097|635<br>0.3|684|0.35|-0.05|609|0.271|634|0.314|-0.043|
|**Length/height-for-age z-score**|695|-1.318|709<br>-1.404|0.086|695<br>-1.318|746|-1.333|0.015|679|-1.436|698|-1.399|-0.037|
|**Weight-for-length/height z-score**|692|0.279|692<br>0.398|-0.119|695<br>0.279|757|0.35|-0.071|685|0.389|687|0.363|0.026|
|**Weight-for-age z-score**|701|-0.528|710<br>-0.527|0.001|701<br>-0.528|758|-0.493|-0.035|684|-0.497|700|-0.498|0.001|

53
# **Microbiology Analysis**

||Contro|l mean<br>**District**<br>**School**|Treatm<br>**level interv**<br>**component**|ent mean<br>**ention**<br>**sample**||
|---|---|---|---|---|---|
||N|Avg.|N|Avg.|Difference|
|**Prevalence of E.Coli in water**|85|0.329|74|0.514|-0.184*|
|**Log10 E. coli, MPN/100ml, Child**|86|0.584|74|0.463|0.121|
|**Log10 E. coli, MPN/100ml, Mother**|86|0.702|74|0.829|-0.127|
|**Log10 E. coli, MPN/100ml, Object**|82|0.595|72|0.621|-0.026|
|**Stool sample, Ascaris detected**|86|0.023|74|0.000|0.023|
|**Stool sample, Blastocystis detected**|86|0.105|74|0.108|-0.003|
|**Stool sample, Giardia detected**|86|0.105|74|0.041|0.064|
|**Parasite count in stools**|86|0.233|74|0.149|0.084|
|**Prevalence ofparasites in stools**<br>*p < 10%, ** < 5%, *** < 1%|86|0.186|74|0.122|0.064|

54
# **Appendix2: Attrition**

## **Household Attrition**

||**Province**<br>**Mass**|**level intervention**<br>**media treatment**||**Commun**|**ity treatment sample**|**District level i**|**ntervention**<br>**School**|**component sample**||
|---|---|---|---|---|---|---|---|---|---|
||Control mean|Treatment mean||Control mean|Treatment mean||Control mean|Treatment mean||
||N<br>Avg.|N<br>Avg.|Difference|N<br>Avg.|N<br>Avg.|Difference|N<br>Avg.|N<br>Avg.|Difference|
|Percentage<br>HHs Included||||||||||
|in Group|707<br>0.7222|717<br>0.8131|-0.0909|707<br>0.722|763<br>0.7614|-0.039|684<br>0.799|705<br>0.835|-0.036|

55
# **Baseline Comparison of Non-Attriters**

|||**Provinc**<br>**Mass**|**e level inte**<br>**media trea**|**rvention**<br>**tment**|||**Commun**|**ity treatme**|**nt sample**|**District level**|**interventio**|**n**<br>**Schoo**|**l componen**|**t sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treatm|ent mean||Cont|rol mean|Treatm|ent mean||Cont|rol mean|Treat|ment mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Average HH size**|546|1.461|583|1.397|0.064|546|1.461|581|1.442|0.02|547|6.177|589|6.014|0.164|
|**Percentage of HH heads that are male**|546|0.91|583|0.907|0.003|546|0.91|581|0.9277|-0.02|547|0.909|589|0.930|-0.022|
|**Percentage of other HH members that are male**|2198|0.37|2563|0.382|-0.012|2198|0.37|2356|0.369|0.00|5030|0.389|5309|0.393|-0.004|
|**Percentage of HH heads that ever attended school**|546|0.961|577|0.949|0.012|546|0.961|581|0.967|-0.01|546|0.962|588|0.973|-0.011|
|**Highest educational level achieved by HH head**||||||||||0.00|||||0.000|
|Primary|524|0.374|546|0.457|-0.083|524|0.374|558|0.416|-0.04|522|0.469|568|0.394|0.075|
|Secondary|524|0.532|546|0.441|**0.091****|524|0.532|558|0.480|0.05|522|0.423|568|0.495|**-0.071***|
|Preparatory|524|0|546|0|-|524|0|558|0.000|0.00|522|0.002|568|0.000|0.002|
|Trade School|524|0.053|546|0.043|0.01|524|0.053|558|0.066|-0.01|522|0.048|568|0.042|0.006|
|University|524|0.04|546|0.056|-0.016|524|0.04|558|0.038|0.00|522|0.057|568|0.069|-0.011|
|**Percentage of teenagers that spent time on:**||||||||||0.00|||||0.000|
|School|552|0.969|673|0.937|0.032|552|0.969|553|0.966|0.00|1103|0.941|1149|0.977|-0.036|
|Studying|552|0.98|669|0.965|0.015|552|0.98|553|0.966|0.01|1103|0.961|1149|0.983|-0.022|
|Children care|553|0.726|669|0.696|0.03|553|0.726|553|0.682|0.04|1105|0.726|1149|0.730|-0.004|
|Homework|553|0.71|669|0.751|-0.041|553|0.71|553|0.731|-0.02|1105|0.692|1149|0.701|-0.008|
|Paid work|553|0.019|670|0.02|-0.001|553|0.019|553|0.007|0.01|1105|0.014|1149|0.005|**0.009**|
|Unpaid work|553|0.074|670|0.167|**-0.009****|553|0.074|553|0.045|0.03|1105|0.074|1149|0.096|-0.022|
|**Percentage of employed HH heads**|546|0.9395|581|0.955|-0.015|546|0.9395|581|0.962|-0.02|545|0.965|589|0.954|0.011|
|**Primary salary**|841|340.48|931|321.09|19.39|841|340.48|926|389.846|-49.37|867|339.348|902|341.755|-2.407|
|**Primary work: hoursper week**|998|43.078|1151|42.513|0.565|998|43.078|1054|41.599|1.48|1044|40.173|1068|41.596|-1.422|
|**Primary work: months worked in last 12 months**|993|9.309|1151|9.807|-0.498|993|9.309|1052|9.711|-0.40|1028|9.346|1057|9.798|**-0.452**|
|**Source of drinking water**||||||||||||||||
|**(Percentage HHS)**||||||||||||||||
|<br>Tanker truck|546|0|583|0.032|**-0.032***|546|0|581|0.002|0.00|546|0.015|589|0.008|0.006|
|Surface water|546|0.034|583|0.082|**-0.048***|546|0.034|581|0.033|0.00|546|0.055|589|0.036|0.019|
|Piped water, into dwelling|546|0.25|583|0.236|0.014|546|0.25|581|0.262|-0.01|546|0.233|589|0.267|-0.034|
|<br>Piped water, into yard, plot|546|0.166|583|0.209|-0.043|546|0.166|581|0.236|-0.07|546|0.167|589|0.224|**-0.057**|
|<br>Piped water, public tap, standpipe|546|0.045|583|0.087|-0.042|546|0.045|581|0.048|0.00|546|0.060|589|0.049|0.011|
|Tube well, worewhole|546|0.027|583|0.008|0.019|546|0.027|581|0.010|0.02|546|0.005|589|0.012|-0.006|
|Dug well, protected|546|0.016|583|0.025|-0.009|546|0.016|581|0.010|0.01|546|0.002|589|0.008|-0.007|
|Dug well, unprotected|546|0.04|583|0.003|0.037|546|0.04|581|0.007|0.03|546|0.026|589|0.008|**0.017**|
|<br>Spring water, protected|546|0.23|583|0.126|0.104|546|0.23|581|0.236|-0.01|546|0.253|589|0.241|0.012|
|<br>Spring water unprotected|546|0.043|583|0.07|-0.027|546|0.043|581|0.022|0.02|546|0.040|589|0.022|0.018|
|,<br>Other|546|0.142|583|0.116|0.026|546|0.142|581|0.134|0.01|546|0.145|589|0.124|0.021|
|**Diarrhea prevalence (Percentage of children under 5)**||||||||||||||||
|2 days<br>|797|0.102|815|0.078|0.024|797|0.102|838|0.095|0.01|816|0.077|840|0.080|-0.003|
|<br>7 days<br>*** p<0.01 ** p<0.05 * p<0.1|797|0.174|815|0.154|0.02|797|0.174|838|0.156|0.02|816|0.145|840|0.140|0.004|

56
# **Comparison of Replacement Households**

|||**Provinc**<br>**Mass**|**e level inte**<br>**media trea**|**rvention**<br>**tment**|||**Commun**|**ity treatmen**|**t sample**|**District level i**|**nterventio**|**n**<br>**School**|**componen**|**t sample**||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||Contr|ol mean|Treat|ment mean||Contr|ol mean|Treatm|ent mean||Con|trol mean|Treat|ment mean||
||N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|N|Avg.|N|Avg.|Difference|
|**Average HH size**|153|4.588|132|4.719|-0.131|153|4.588|179|4.587|0.002|122|4.852|115|5.130|-0.278|
|**Percentage of HH heads that are male**|152|0.921|131|0.931|-0.01|152|0.921|179|0.860|0.061|122|0.877|114|0.860|0.017|
|**Percentage of other HH members that are male**|550|0.383|492|0.369|0.014|550|0.384|642|0.399|-0.015|470|0.402|476|0.391|0.011|
|**Percentage of HH heads that ever attended school**|150|0.946|131|0.961|-0.015|153|1.216|179|1.268|-0.052|122|1.320|115|1.209|**0.111****|
|**Highest educational level achieved by HH head**||||||||||0.000|||||0.000|
|Primary|119|0.184|101|0.207|-0.023|150|0.947|179|0.961|-0.014|122|0.975|114|0.921|0.054|
|Secondary|119|0.1|101|0.099|0.001|141|0.333|171|0.380|-0.047|117|0.282|103|0.398|**-0.116****|
|Preparatory|119|0.512|101|0.455|0.057|141|0.553|171|0.497|0.056|117|0.547|103|0.534|0.013|
|Trade school|119|0.193|101|0.237|-0.044|141|0.092|171|0.064|0.028|117|0.120|103|0.039|0.081|
|University|119|0.008|101|0|0.008|141|0.021|171|0.058|-0.037|117|0.051|103|0.029|0.022|
|**% of employed HH heads**|152|0.96|131|0.938|0.022|152|0.961|179|0.939|0.022|122|0.893|114|0.921|-0.028|
|**Source of drinking water**||||||||||0.000|||||0.000|
|**(% HHS)**||||||||||||||||
|Tanker truck|153|0|132|0|-|153|0.000|179|0.000|0.000|122|0.008|115|0.000|0.008|
|Water vendor|153|0|132|0|-|153|0.000|179|0.000|0.000|122|0.016|115|0.000|0.016|
|Surface water|153|0.019|132|0.022|-0.003|153|0.020|179|0.039|-0.019|122|0.016|115|0.043|-0.027|
|Bottled water|153|0.013|132|0|0.013|153|0.013|179|0.000|0.013|122|0.025|115|0.000|0.025|
|Piped water, into dwelling|153|0.281|132|0.333|-0.052|153|0.281|179|0.296|-0.015|122|0.320|115|0.426|-0.106|
|Piped water, into yard, plot|153|0.464|132|0.356|0.108|153|0.464|179|0.486|-0.022|122|0.393|115|0.357|0.037|
|Piped water, public tap, stand|153|0.071|132|0.136|-0.065|153|0.072|179|0.056|0.016|122|0.066|115|0.017|0.048|
|Dug well, protected|153|0.065|132|0|0.065|153|0.065|179|0.011|0.054|122|0.033|115|0.000|0.033|
|Dug well, unprotected|153|0|132|0.015|-0.015|153|0.000|179|0.000|0.000|122|0.000|115|0.017|-0.017|
|Spring water, protected|153|0.032|132|0.068|-0.036|153|0.033|179|0.017|0.016|122|0.008|115|0.043|-0.035|
|<br>Spring water, unprotected|153|0.019|132|0.037|-0.018|153|0.020|179|0.011|0.008|122|0.008|115|0.009|0.000|
|<br>Rainwater|153|0|132|0|-|153|0.000|179|0.006|-0.006|122|0.000|115|0.000|0.000|
|Other|153|0.026|132|0.015|0.011|153|0.026|179|0.050|-0.024|122|0.107|115|0.070|0.037|
|*** p<0.01 ** p<0.05 * p<0.1|*** p<0.01 *|* p<0.05 * p<0.1||||||||||||||

57
# **Appendix 3: Robustness Checks**

## **Mass Media Treatment**

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Exposure**<sup>**~~+~~**</sup>|||||
|High exposure to the treatments|0.147|0.0266|0.0145|0.0039|
|<br>(HW message through three channels)||(0.040)|(0.037)|(0.037)|
|Medium exposure to the treatments<br>(HW message through two channels)|0.432|0.0308<br>(0.061)|0.0145<br>(0.057)|-0.00929<br>(0.058)|
|Low exposure to the treatments|0.674|-0.0343|-0.0457|-0.0613|
|(HW message through one channel)||(0.054)|(0.054)|(0.056)|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *<br>+Channels: mass media (radio and/or printed|** p<0.01 ** p<0.05 * p<br>materials), promotiona|NO<br><0.1<br>l events and perso|NO<br>nal training/educatio|YES<br>nal sessions|

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Knowledge**|||||
|Events that require handwashing (summary index)|0.225|0.0221<br>(0.018)|0.0215<br>(0.019)|0.02<br>(0.019)|
|Best method to wash hands is using water and soap<br>(Percentage)|0.879|0.005<br>(0.028)|0.0115<br>(0.025)|-0.003<br>(0.021)|
||0.94|-0.002|-0.001|-0.006|
|Main cause of diarrhea is not washing hands with water<br>and soap (Percentage)||(0.016)|(0.016)|(0.014)|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors inparentheses;***p<0.01 **p<0.05|*p<0.1||||

58
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Handwashing facilities**|||||
|HW Facilities stocked with water and soap (=1)|0.653|-0.029<br>(0.057)|-0.031<br>(0.058)|-0.019<br>(0.057)|
|Water and soap anywhere in the house (=1)|0.787|-0.028<br>(0.040)|-0.029<br>(0.040)|-0.025<br>(0.040)|
|**Hand cleanliness**|||||
|Hands Cleanliness Index|7.527|-0.327<br>(0.204)|-0.294*<br>(0.177)<br>[3.9%]|-0.178<br>(0.166)|
|**Self-Reported handwashing behaviour**|||||
|HW with soap and water previous to eat|0.415|-0.166***<br>(0.040)|-0.162***<br>(0.038)|-0.156***<br>(0.040)|
|||[-40%]|[-39%]|[-37.5%]|
|HW with soap and water before food prep.|0.653|0.0054<br>(0.037)|0.009<br>(0.037)|-0.007<br>(0.037)|
|HW with soap and water after fecal contact|0.654|-0.088**<br>(0.037)<br>[-13.4%]|-0.092**<br>(0.037)|-0.084**<br>(0.040)<br>[-12.8%]|
|HW with soap and water before feeding child|0.206|0.036<br>(0.029)|0.032<br>(0.030)|0.037<br>(0.031)|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors in parentheses; *** p<0.01 **|p<0.05 * p<0.1||||

59
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Child health**(children < 5years old)|||||
|Diarrhea prevalence 48 hours|0.04|0.014|0.013|0.01|
|||(0.014)|(0.013)|(0.013)|
|Diarrhea prevalence 7 days|0.06|0.019|0.017|0.011|
|||(0.019)|(0.018)|(0.018)|
|ALRI prevalence 48 hours|0.041|-0.035***<br>(0.013)|-0.035**<br>(0.014)|-0.039***<br>(0.014)|
|||[-96%]|[-96%]|[-96.5%]|
|ALRI prevalence 7 days|0.051|-0.042**<br>(0.017)|-0.041**<br>(0.016)|-0.047**<br>(0.018)|
|||[-82.3%]|[-80.3%]|[-89%]|
|Weight-for-age z-score|-0.69|0.0616|0.037|0.106|
|||(0.098)|(0.092)|(0.094)|
|Length/Height-for-age z-score|-1.453|-0.0328|-0.034|0.0371|
|||(0.106)|(0.091)|(0.080)|
|Weight-for-length/height z-score|0.203|0.119|0.12|0.140*|
|||(0.079)|(0.078)|(0.077)|
|Anemia (Hb < 110 g/L)|0.283|-0.0321|-0.0374|-0.046|
|||(0.036)|(0.032)|(0.033)|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *** p<0|.01 ** p<0.05 * p<0.1|NO|NO|YES|

60
# **Community Treatment**

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Exposure**<sup>**~~+~~**</sup>|||||
|High exposure to the treatments|0.147|0.0750*|0.0491|0.0551|
|(HW message through three channels)||(0.042)|(0.037)|(0.037)|
|Medium exposure to the treatments|0.432|0.176***|0.138**|0.145***|
|(HW message through two channels)||(0.059)<br>[40%]|(0.054)<br>[32%]|(0.051)<br>[34%]|
|Low exposure to the treatments|0.674|0.127**|0.103**|0.106**|
|(HW message through one channel)||(0.050)<br>[19%]|(0.047)<br>[15%]|(0.045)<br>[16%]|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *<br>+Channels: mass media (radio and/or printed|** p<0.01 ** p<0.05 *<br>materials), promotion|NO<br>p<0.1<br>al events and person|NO<br>al training/educatio|YES<br>nal sessions|

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Knowledge**|||||
|Events that require handwashing (summary index)|0.225|0.0152<br>(0.020)|0.007<br>(0.020)|0.009<br>(0.020)|
|Best method to wash hands is using water and soap (Percentage)|0.879|0.0402<br>(0.028)|0.0539*<br>(0.025)<br>[6.1%]|0.0512*<br>(0.021)<br>[5.8%]|
|Main cause of diarrhea is not washing hands with water and soap<br>(Percentage)|0.94|0.0272**<br>(0.012)<br>[2.8%]|0.0320**<br>(0.013)<br>[3.4%]|0.0313**<br>(0.012)<br>[3.2%]|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *** p<0.01 ** p<0.05 * p<0.1||NO|NO|YES|

61
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Handwashing facilities**|||||
|HW Facilities stocked with water and soap (=1)|0.653|0.0238<br>(0.049)|0.0406<br>(0.048)|0.0326<br>(0.048)|
|Water and soap anywhere in the house (=1)|0.787|0.0126<br>(0.039)|0.0279<br>(0.039)|0.0267<br>(0.038)|
|**Hand cleanliness**|||||
|Hands Cleanliness Index|7.527|0.245<br>(0.184)|0.278*<br>(0.161)<br>[3.7%]|0.246<br>(0.154)|
|**Self-Reported handwashing behaviour**|||||
|HW with soap and water previous to eat|0.415|0.011<br>(0.046)|0.025<br>(0.046)|0.036<br>(0.044)|
|HW with soap and water before food prep.|0.653|0.002<br>(0.043)|0.017<br>(0.038)|0.027<br>(0.037)|
|HW with soap and water after fecal contact|0.654|-0.004<br>(0.044)|0.015<br>(0.042)|0.0254<br>(0.038)|
|HW with soap and water before feeding child|0.206|0.000<br>(0.030)|0.002<br>(0.030)|0.004<br>(0.030)|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors in parentheses; *** p<0.01 **|p<0.05 * p<0.1||||

62
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Child health**(children < 5years old)|||||
|Diarrhea prevalence 48 hours|0.040|-0.006<br>(0.011)|-0.003<br>(0.011)|-0.002<br>(0.011)|
|Diarrhea prevalence 7 days|0.060|-0.001<br>(0.016)|0.001<br>(0.016)|0.002<br>(0.016)|
|ALRI prevalence 48 hours|0.041|-0.008<br>(0.019)|-0.014<br>(0.018)|-0.011<br>(0.019)|
|ALRI prevalence 7 days|0.051|-0.009<br>(0.024)|-0.019<br>(0.022)|-0.017<br>(0.022)|
|Weight-for-age z-score|-0.69|0.006|0.041|0.000|
|||(0.099)|(0.089)|(0.085)|
|Length/Height-for-age z-score|-1.453|-0.013|-0.019|-0.056|
|||(0.099)|(0.086)|(0.080)|
|Weight-for-length/height z-score|0.203|0.074|0.111|0.076|
|||(0.086)|(0.082)|(0.079)|
|Anemia (Hb < 110 g/L)|0.283|-0.049<br>(0.037)|-0.039<br>(0.035)|-0.026<br>(0.033)|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors in parentheses; *** p<0.|01 ** p<0.05 * p<0.1||||

63
# **School Component Sample of Community Treatment**

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Exposure**<sup>**~~+~~**</sup>|||||
|High exposure to the treatments<br>(HW message through three channels)|0.2|0.0113<br>(0.047)|-0.0207<br>(0.043)|-0.0275<br>(0.043)|
|Medium exposure to the treatments|0.499|0.100*|0.0659|0.065|
|(HW message through two channels)||(0.058)|(0.051)|(0.050)|
|Low exposure to the treatments|0.717|0.0851*|0.0591|0.0637|
|(HW message through one channel)||(0.046)|(0.041)|(0.039)<br>[8.9%]|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *<br>+Channels: mass media (radio and/or printed|** p<0.01 ** p<0.05 * p<br>materials), promotiona|NO<br><0.1<br>l events and perso|NO<br>nal training/educatio|YES<br>nal sessions|

||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Knowledge**|||||
|Events that require handwashing (summary index)|0.222|0.0188<br>(0.021)|0.00894<br>(0.020)|0.0159<br>(0.020)|
|Best method to wash hands is using water and soap (Percentage)|0.882|0.0513**<br>(0.023)|0.049**<br>(0.021)|0.044**<br>(0.022)|
|||[5.7%]|[5.5%]|[4.9%]|
|Main cause of diarrhea is not washing hands with water and soap|0.94|0.0131<br>(0.016)|0.0163<br>(0.016)|0.0118<br>(0.015)|
|Controls||NO|YES|YES|
|District dummies<br>Clustered standard errors in parentheses; *** p<0.01 ** p<0.05 * p<0.1||NO|NO|YES|

64
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Handwshing facilities**|||||
|HW facilities stocked with water and soap (=1)|0.67|0.057<br>(0.045)|0.071<br>(0.044)|0.062<br>(0.043)|
|Water and soap anywhere in the house (=1)|0.768|0.056<br>(0.034)|0.065**<br>(0.033)|0.067**<br>(0.033)|
||||[8.4%]|[8.7%]|
|**Hand cleanliness**|||||
|Hands Cleanliness Index|7.403|0.205<br>(0.172)|0.226<br>(0.158)|0.21<br>(0.151)|
|**Self-Reported handwashing behaviour**|||||
|HW with soap and water previous to eat|0.402|0.056|0.069|0.095**|
|||(0.050)|(0.049)|(0.044)|
|HW with soap and water before food prep.|0.694|-0.052<br>(0.041)|-0.047<br>(0.040)|-0.042<br>(0.039)|
|HW with soap and water after fecal contact|0.656|-0.0121<br>(0.050)|-0.0000743<br>(0.049)|0.0199<br>(0.043)|
|HW with soap and water before feeding child|0.194|0.0387<br>(0.034)|0.0526*<br>(0.031)|0.0546*<br>(0.030)|
||||[27%]|[28%]|
|**Structured observations**|||||
|Observed HW with soap previous to feeding baby|0.076|-0.001<br>(0.048)|0.001<br>(0.054)|0.04<br>(0.060)|
|Observed HW with soap after fecal contact|0.342|-0.028<br>(0.059)|-0.021<br>(0.054)|-0.022<br>(0.056)|
|Observed HW with soap previous to preparing food|0.099|0.067|0.077**|0.068*|
|||(0.041)|(0.038)|(0.038)|
|||[67.6%]|[77.7%]|[68.6%]|
|Observed HW with soap previous to eat|0.189|0.096*|0.101**|0.115**|
|||(0.050)|(0.047)|(0.049)|
|||[50.7%]|[53.4%]|[60.8%]|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors in parentheses; *** p<0.01 ** p<0.0|5 * p<0.1||||

65
||Control mean|(1)|(2)|(3)|
|---|---|---|---|---|
|**Child health**(children < 5years old)|||||
|Diarrhea prevalence 48 hours|0.033|0.000|-0.002|0.001|
|||(0.010)|(0.010)|(0.010)|
|Diarrhea prevalence 7 days|0.061|-0.005<br>(0.015)|-0.005<br>(0.014)|-0.005<br>(0.014)|
|ALRI prevalence 48 hours|0.049|-0.011<br>(0.022)|-0.017<br>(0.020)|-0.018<br>(0.020)|
|ALRI prevalence 7 days|0.056|-0.012|-0.020|-0.021|
|||(0.025)|(0.023)|(0.023)|
|Weight-for-age z-score|-0.82|0.0994|0.148|0.107|
|||(0.094)|(0.091)|(0.087)|
|Length/Height-for-age z-score|-1.619|0.12|0.119|0.0833|
|||(0.094)|(0.091)|(0.088)|
|Weight-for-length/height z-score|0.165|0.0743|0.135|0.106|
|||(0.090)|(0.083)|(0.083)|
|Anemia (Hb < 110 g/L)|0.278|-0.040|-0.027|-0.022|
|||(0.033)|(0.029)|(0.029)|
|**Parasites in child stools**|||||
|Prevalence of parasites|0.227|-0.016|-0.051|-0.045|
|||(0.055)|(0.046)|(0.041)|
|Parasite count|0.303|-0.033|-0.085|-0.068|
|||(0.078)|(0.062)|(0.053)|
|Controls||NO|YES|YES|
|District dummies||NO|NO|YES|
|Clustered standard errors in parentheses; *** p<|0.01 ** p<0.05 * p<0.1||||

66
# **Appendix 4: Variable Description**

|Variable|Unit of Observation|Description|Total Number of Observations (endline)|
|---|---|---|---|
|Individual Characteristics||||
|Age: Head of HH|Head of HH|Average age in years|3,518|
|Age: Other HH members|Other HH members|Average age inyears|14,981|
|Gender(male): Head of HH|Head of HH|Malegender indicator|3,518|
|Gender(male): Other HH members|Other HH members|Malegender indicator|14,981|
|Average number of children under 5|HH|Children under 5per HH|3,563|
|Average household size|HH|Membersper HH|3,547|
|Percent of Heads of HH that ever attended school|Head of HH|-|3,495|
|Highest educational level achieved: Head of HH|Head of HH|-|3,308|
|Percent of other HH members that ever attended<br>school|Other HH members|-|10,345|
|Highest educational level achieved: other HH<br>members|Other HH members|-|9,840|
|Percent of teenagers that spent time on school and<br>other activities|Attending school individuals|Positive hours indicator|19903|
|Percent of employed heads of HH|Head of HH|Employment status indicator|3,514|
|Last week activity: head of HH|Unemployed head of HH|-|225|
|Percent of employed other HH members|Other HH members|Employment status indicator, +15<br>years|5,224|
|Last week activity: other HH members|Unemployed other HH members|-|3,328|
|Primarywork:position|Employed individuals|-|6,797|
|Primarywork: monthlysalary|Employed individuals|-|5,850|
|Primarywork: hoursper week|Employed individuals|-|6797|
|Primarywork: months worked in last 12 months|Employed individuals|-|6,797|
|Households Assets||||
|HH’s assets|Household|Possession of assets indicator|3,547|
|Percent of HHs havingotherpiece of land|Household|Landpossession indicator|3,547|
|Percent of HHs having farm equipment|Household|Farm equipment possession<br>indicator|3,547|
|Percent of HHs havinganimals|Household|Animalpossession indicator|3,547|
|Average number of livestock owned|Household|Average number of total livestock<br>owned|3.547|
|Dwellingownership|Household|-|3,547|

67
|Dwelling Characteristics<br>||||
|---|---|---|---|
|Type of dwelling|Household|-|3,544|
|Dwellinglight source|Household|-|3,547|
|Dwellingcookingfuel|Household|-|3,5447|
|Dwellingheat fuel|Household|-|3,547|
|Material of dwelling's walls|Household|-|3,544|
|Material of dwelling's roof|Household|-|3,544|
|Material of dwelling's floor|Household|-|3,543|
|Percent of HHs with food not covered|Household|-|3,055|
|Percent of clean HHs|Household|-|3,527|
|Percent of HHs withgarbage in kitchen or house|Household|-|3,255|
|Main toilet facility|Household|-|3,547|
|Toilet Facilities||||
|Percent of toilet facilities that arepublic|Household|-|3,033|
|Location of main toilet facility|Household|-|3,547|
|Percent of shared toilet facility|Household|-|3,547|
|Percent of safe toilet facilities duringthe night|Household|-|3,547|
|Disposal of child defecation|Household|-|3,547|
|Improved water source|Household|-|3,492|
|Improved sanitation|Household|-|3,547|
|Soapand water at handwashingstation|Household|-|3,547|
|Water Source||||
|||Rain station onl Smaller||
|Source of drinking water|Household|y y,<br>categoriesgrouped in Other|3,547|
|Source location|Household|Rainystation only|263|
|Covered source|Household|Rainystation only|263|
|Who mainlycollects water from this source|Household|Rainystation only|806|
|Satisfied with thequantity|Household|Rainystation only|3,526|
|Does the householdpayfor the water|Household|Rainystation only|3,529|
|Fixed, limitedquantityobtained for thepayment|Household|Rainystation only|2,374|
|How water wasprepared(last seven days)|Household|-|3,067|
|Wash hands aftergoingto toilet|Household|Yes/No: AnyHH member|3,526|
|Handwashing Facilities||||
|Place where usually wash hands after going to toilet|Household|-|3,435|

68
|Handwashingdevice, toilet|Household|-|3,252|
|---|---|---|---|
|Water available at handwashingstation|Household|-|1107|
|Soapavailable|Household|Allows multiple answers|3,547|
|Wash hands before/after cooking, feedinga child|Household|AnyHH member|3,529|
|Place where usually wash hands before/after cooking,<br>feedinga child|Household|-|3,49|
|Handwashing facilities stocked with water and soap|Household|Percent of HH that have a place to<br>wash hands inside the house or in<br>the yard (in this case, ONLY if it less<br>than 3 meters away from a<br>bathroom); the place must have<br>water available and soap of any<br>kind.|3,547|
|Water and soap anywhere in the house|Household|Percent of HH that have a place to<br>wash hands (anywhere) with water<br>available and soapof anykind.|3,547|
|Exposure Measures||||
|High exposure to the treatments|Caregivers|Percent of caregivers exposed to<br>handwashing promotion through<br>three channels (mass media,<br>promotional events and<br>training/educational sessions)|3,545|
|Medium exposure to the treatments|Caregivers|Percent of caregivers exposed to<br>handwashing promotion through<br>two channels (mass media and either<br>promotional events or<br>training/educational sessions)|3,545|
|Low exposure to the treatments|Caregivers|Percent of caregivers exposed to<br>handwashing promotion through<br>one channel only (mass media or<br>promotional events or|3,545|
|||training/educational sessions)||
|HandwashingKnowledge||||
|Events that require handwashing (summary index)|Caregivers|Proportion of “yes” answers to the<br>following questions:<br>“When do you think it is necessary<br>to wash your hands with soap? A)<br>After cleaning baby bottom; B) After<br>using the toilet, C) Before Eating; D)<br>Before feeding the baby; E) Before<br>preparingfood”.|3,591|
|Best method to wash hands is usingwater and soap (|Caregivers|Percent of caregivers that answer|3,553|

69
|percent)||“washing hands with water and<br>soap” to the following question:<br>“What is the best way to clean<br>hands”||
|---|---|---|---|
|Main cause of diarrhea is not washing hands with water<br>and soup ( percent)|Caregivers|Percent of caregivers that mention<br>“Not washing hands with water and<br>soap” to the following question:<br>“What causes diarrhea?”|3,582|
|Family-School Relationship<br>Pt f i tht ll i hlth||||
|ercen o caregvers a reca any campagn on ea<br>and hygiene promoted by the school|Caregiver of child attending<br>primary school|-|2,376|
|HandwashingBehavior||||
|Percent of caregivers that washed their hands with soap<br>sinceyesterday|Caregiver of child under the<br>age of 5|-|3,579|
|Last moment of hand wash since yesterday|Caregiver of child under the<br>age of 5|Allows multiple answers|3,196|
|Best way to clean hands|Caregiver of child under the<br>age of 5|Allows multiple answers|3,553|
|Caregiver's fingernails are:|Caregiver of child under the<br>age of 5|-|3,556|
|Caregiver's palms are:|Caregiver of child under the<br>age of 5|-|3,556|
|Caregiver's finger pads are:|Caregiver of child under the<br>age of 5|-|3,556|
|Recalls of any handwashing campaign|Caregiver of child under the<br>age of 5|-|3,543|
|Participation in schools activities|Caregiver of child attending<br>primaryschool|Allows multiple answers|3,543|
|Hands Cleanliness Index|Caregiver of child attending<br>primary school|Index composed by three elements:<br>•<br>Nails: +1 if visibly dirty, +2<br>if apparently dirty, +3 if<br>clean.<br>•<br>Palms: +1 if visibly dirty,<br>+2 if apparently dirty, +3 if<br>clean.<br>•<br>Fingerpads: +1 if visibly<br>dirty, +2 if apparently dirty,<br>+3 if clean.<br>The range of the index is from 3 to 9,<br>and itgoes upwhen hands are|3,549|

70
|||cleaner.||
|---|---|---|---|
|Handwashing w/soap and water previous to eat|Caregiver|Self-reported handwashing with<br>soap previous to eat|3,560|
|Handwashing w/soap and water before food preparation|Caregiver|Self-reported handwashing with<br>soapbeforepreparingfood|3,560|
|Handwashing w/ soap and water after fecal contact|Caregiver|Self-reported handwashing with<br>soap after fecal contact (after using<br>the bathroom/after changingdiaper)|3,560|
|Handwashing w/ soap and water before feeding child|Caregiver|Self-reported handwashing with<br>soapbefore feedingchild|3,560|
|Structured Observations||||
|Observed handwashing w/soap and water previous to eat|Caregiver|Observed handwashing with soap<br>prior to eating|1,255|
|Observed handwashing w/soap and water before food<br>preparation|Caregiver|Observed handwashing with soap<br>before preparing food|1,256|
|Observed handwashing w/soap and water after fecal<br>contact|Caregiver|Observed handwashing with soap<br>after fecal contact (after using the<br>bathroom/after changingdiaper)|901|
|Observed handwashing w/soap and water before feeding<br>child|Caregiver|Observed handwashing with soap<br>before feedin child|250|
|||g||
|Childcare Situation||||
|Percent of children with clean aspect|Children under the age of 5|-|4,563|
|Percent of children with dirtyhands|Children under the age of 5|-|4,563|
|Percent of children with dirtyfinger nails|Children under the age of 5|-|4,563|
|Percent of children with dirtyface|Children under the age of 5|-|4,563|
|Percent of children wearingclothes|Children under the age of 5|-|4,563|
|Percent of children with dirtyclothes|Children under the age of 5|-|4,563|
|Percent of children withpot-belly|Children under the age of 5|-|4,563|
|Percent of children wearingshoes(or shoes available)|Children under the age of 5|-|4,563|
|Percent of children thatplaywith household objects|Children under the age of 5|-|688|
|Percent of children thatplaywith toys|Children under the age of 5|-|688|
|Average number of children's books orpictures|Children under the age of 5|-|688|
|Percent of children that attended earlyeducationprograms|Children under the age of 5|-|688|
|Percent of adults that read books with child|Children under the age of 5|-|688|
|Percent of adults that tell stories to the child|Children under the age of 5|-|688|
|Percent of adults that take the child outside the home|Children under the age of 5|-|688|
|Percent of adults thatplaywith the child|Children under the age of 5|-|688|

71
|Average daily caring time|Caregiver of child under the<br>age of 5|-|4,404|
|---|---|---|---|
|Child Development||||
|||Z-score computed child||
|ASQ communication skills-for-age z-score|Children under the age of 5|development index based on<br>caregivers responses to certain|3,628|
|ASQ gross-motor skills-for-age z-score|Children under the age of 5|child’s reactions to specific stimuli<br>and achieved milestones. The<br>questions were based on the Ages<br>and Stages Questionnaire and the|3,624|
|ASQ social-personal skills-for-age z-score|Children under the age of 5|skills measured included three<br>domains: communications, gross-<br>motor and social/personal skills.<br>ae|3,627|
|||g.||
|Average number of times child was left at the charge of<br>another child|Children under the age of 2|-|688|
|Average number of times was child left alone|Children under the age of 2|-|688|
|Child Health||||
|||ALRI symptoms: constant cough or||
|ALRI prevalence (48 hours)|Children under the age of 5|<br>difficulty breathing, and raised<br>|4,563|
|ALRI prevalence (7 days)|Children under the age of 5|respiratory rate (according to WHO)|4,563|
|Diarrhea prevalence (48 hours)|Children under the age of 5|Diarrhea symptoms: 3 or more stools<br>per day and stools were loose or<br>|4,563|
|Diarrhea prevalence (7 days)|Children under the age of 5|watery, or blood and/or mucus<br>were present in stool.|4,563|
|Anemia (Hb < 110 g/L)|Children under the age of 5|Percent of children under 5 with<br>hemoglobin levels < 100 g/L.<br>Hemoglobin counts were altitude-<br>adjusted|4,083|
|Anthropometric Measures||||
|BMI-for-age z-score|Children under the age of 5|Z-scores were adjusted taking into|4,347|
|Head circumference-for-age z-score|Children under the age of 5|<br>account child’s age; values outside<br>|4,375|
|Length/height-for-age z-score|Children under the age of 5|reasonable bounds were not<br>idd flli|4,354|
|Arm circumference-for-age z-score|Children under the age of 5|consere (oowng|4,342|

72
|Weight-for-length/height z-score|Children under the age of 5|recommendations by WHO)|4,343|
|---|---|---|---|
|Weight-for-age z-score|Children under the age of 5|BMI stands for body mass index.|4,369|
|Prevalence of stunting ( percent)|Children under the age of 5|Percent of children under 5 whose<br>length/height-for-age indicator is<br>less than 2 SD from its Z-score mean.|4,354|
|Prevalence of underweight ( percent)|Children under the age of 5|Percent of children under 5 whose<br>weight-for-age indicator is less than<br>2 SD from its Z-score mean.|4,369|
|Prevalence of wasting ( percent)|Children under the age of 5|Percent of children under 5 whose<br>weight-for-length indicator is less<br>than 2 SD from its Z-score mean.|4,343|
|Water Contamination||||
|Prevalence of E.Coli|Children under 5|=1 if_E.Coli_> 0.013 NMPx mL, 0<br>otherwise<br>Water collected onlyin T3|575|
|Prevalence of total coliforms|Children under 5|=1 if_Total Coliforms_> 0.013 NMPx<br>mL, 0 otherwise<br>Water collected onlyin T3|575|
|Parasite Prevalence||||
|Prevalence of any parasites|Children under 5|Percent of children with any<br>parasites (Trichura, Ascaris,<br>Uncinaria or others) detected in stool<br>samples|1,552|
|Parasite count|Children under 5|Parasite count present in child’s<br>stool sample. It sums 1 for each<br>different type of parasite found on<br>the sample (Trichura, Ascaris,<br>Uncinaria,Others)|1,552|

73