Evaluating The Hunger Project’s Epicenter Scale-Up Project in Eastern Ghana

Given the interconnected challenges poor families often face, many practitioners in international development believe that breaking the cycle of poverty in extremely poor communities requires a multi-faceted and participatory approach. In rural Ghana, researchers evaluated the impact of a community-driven development program on community members’ health, education, nutrition, livelihoods, access to finance, and local governance.

Policy Issue:

Very poor households often face a set of interconnected challenges that may keep them in extreme poverty. For example, malnourished children may have difficulty succeeding in school; families without financial services may turn to predatory lenders when cash-strapped; poorer, less educated households may be less likely to participate in politics and, in turn, gain political power. Given these interconnected challenges, many practitioners in international development argue that breaking the poverty cycle requires a multi-faceted and participatory approach, and that tackling multiple issues at once can have a “multiplier effect” and quicken the pace of development. Yet there is relatively little evidence on the effectiveness of these types of participatory community driven development programs.

Context of the Evaluation:

The international NGO The Hunger Project (THP) implements a community-driven development program called the Epicenter Strategy in eight countries across Africa. It aims to mobilize rural communities to lead a series of self-help initiatives to reduce their own hunger and poverty. The multi-year program features four phases: an initial mobilization phase in which THP provides training to mobilize communities to commit to creating positive change, a construction phase in which communities partner with THP to construct the epicenter building, and the program implementation stage, and the transition to self-reliance stage.

Each epicenter building houses a clinic, a microfinance bank, a three-acre farm, a food storage unit, and either a kindergarten or library. To construct the centers, communities must contribute in cash or in kind, while THP provides some construction materials. Once a center is constructed, it provides community programs that address health, food security, education, agriculture, and household finance needs. After several years of operation, THP transitions out of supporting the epicenter with the goal that communities will fully take over its operation.

Details of the Intervention:

Researchers evaluated the impact of THP’s Epicenter Strategy on 36 outcomes in eight areas: community mobilization; gender equality; food security; literacy and education; health and nutrition; water, environment, and sanitation; livelihoods and microfinance; and governance. The evaluation took place in 13 districts in eastern Ghana in which THP had not worked prior to the evaluation.

Each district was divided into roughly eight clusters of about 10,000 people each. Fifty-five clusters were randomly assigned to receive the Epicenter Strategy via public lottery and 50 were assigned to the comparison group. Researchers randomly selected 20 households from two villages within each cluster in both the treatment and comparison groups (approximately 3,800 households) and measured changes in these households well-being over a five-year period.

The intervention consisted of active promotion of epicenters in the treatment clusters, in which THP conducted workshops and outreach activities with village volunteers, construction of the centers, implementation of programs, and transitioning to self-reliance (in which THP withdraws support).

Results and Policy Lessons:

Results forthcoming.

An Entrepreneurial Model of Community Health Delivery in Uganda

Despite a substantial decline in child mortality in recent years, millions of children still die from preventable diseases every year. In this study in rural Uganda, researchers evaluate the impact of a micro-franchise model, which incentivizes door-to-door health workers, on under-five mortality rates.

Policy Issue:

In a world with underserved populations who have inadequate access to basic health services, an increasingly common approach to reaching these populations is community health worker programs. These programs aim to improve health outcomes among groups that have traditionally lacked access to adequate health care by recruiting community members to serve as connectors between healthcare consumers and providers.2 However, evidence indicates that there are mixed evidence of this approach in reducing child mortality.3 Weak incentives for community health workers to deliver timely and appropriate services are believed to limit the effectiveness of these programs.4 A potential solution may be financially sustainable delivery models where the health workers earn a margin on product sales and small performance-based incentives. This study in Uganda assesses the impact of such a non-profit entrepreneurial model of community health delivery.

Context of the Evaluation:

Although infant and under-five deaths in Uganda have declined substantially is recent years, 69 out of 1,000 children in the country still die before age five.5 To reach an international target of reducing the under-five mortality rate by two thirds, Uganda will need to sustain a rapid rate of progress. 6

Living Goods, a U.S.-based non-governmental organization, created Living Goods Community Health Promoters (CHPs), with the aim of improving access to and adoption of simple, proven health interventions in rural and peri-urban areas in Uganda. The program is carried out in partnership with the Bangladesh-based non-profit BRAC. CHPs are women trained to operate micro-franchises, which sell a line of health products below market price, door-to-door to households in their communities. Apart from providing health education and access to basic health products at low costs, this model aims to create sustainable livelihoods for the CHPs, who operate with financial incentives to meet household demand and receive small performance-based incentives for home visits and referrals.

Details of the Intervention:

Researchers carried out a randomized evaluation to evaluate the impact of the Living Goods and BRAC Community Health Promoters (CHP) program on under-five mortality rate in rural Uganda. Researchers randomly assigned 214 villages across 10 districts to either the treatment group, which received the CHP program, or the comparison group, which did not receive the program.

Over a three-year period, CHPs conducted home visits in the 115 villages in the treatment group, educating households on essential health behaviors and offering preventive and curative health products for sale at 20-30 percent below prevailing retail prices. Prevention products included long-lasting insecticide treated mosquito nets, vitamins, and water purification tablets. Curative treatments included antibiotics, antimalarial drugs, oral rehydration salts, and zinc. Additionally, in order to incentivize the CHPs to provide maternal, newborn, and child health services, Living Goods pay CHPs US$0.20 for every home visit within 48 hours of delivery.

Ninety-nine villages did not receive the program and served as a comparison group. On average, around 38 households were surveyed per village at the end of 2013, for a total sample size of approximately 8,100 households.IPA conducted the final household survey in 2013, approximately three years of Community Health Promoters operating in the treatment villages. The primary study outcome is under-five child mortality rate over the period 2011-2013.

[Note: IPA only implemented final data collection, in 2013.

Results and Policy Lessons:

Results forthcoming.


[1] UNICEF. Millennium Development Goals: Child Mortality.

[2] Witmer, Anne, Sarena D. Seifer, Leonard Finocchio, Jodi Leslie, and Edward H. O'Neil. "Community health workers: integral members of the health care work force." American Journal of Public Health 85, no. 8_Pt_1 (1995): 1055-1058.

[3] Lewin, Simon, Susan Munabi-Babigumira, Claire Glenton, Karen Daniels, Xavier Bosch-Capblanch, Brian E. van Wyk, Jan Odgaard-Jensen et al. “Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.” Cochrane Database Syst Rev 3 (2010).

[4]“Community and Formal Health System Support for Enhanced Community Health Worker Performance: A U.S. Government Evidence Summit” USAID Final Report 2012.

[6] Millennium Development Goals Report 2013: Drivers of MDG Progress in Uganda and the Implications for the Post-2015 Development Agenda.

Communal Sanitation Solutions for Urban Slums in Orissa, India

In densely populated and rapidly growing countries, severe space constraints, poor utilities infrastructure, and temporary housing construction can render private household sanitation facilities infeasible. Researchers are evaluating the effect of improving communal toilet facilities, and implementing innovative systems for facility maintenance, on the use of community toilets in Orissa, India.

Policy Issue:

In densely populated and rapidly growing countries, severe space constraints, poor utilities infrastructure, and temporary housing construction can render private household sanitation facilities infeasible. Improving communal toilets, which serve entire neighborhoods, may be a more feasible way to improve sanitation, health and well-being in such densely populated areas. However, these kinds of facilities face their own set of problems. Because the benefits of cleaner facilities extend beyond the individual, people may be unwilling to help with repair and maintenance. When the toilets then fall into disrepair, people often revert to open defecation, leading communal toilets to be abandoned. Can innovative systems of facility management help overcome these “collective action” problems and make communal toilets a sustainable option in urban slums?

Context of the Evaluation:

In the slums of Bhubaneswar and Cuttack in India, almost 45 percent  of households use either public toilets, which are meant for a rotating population in commercial areas, or communal toilets, which serve a fixed residential population. However, the condition of these facilities is very poor. A preliminary survey showed that 53 percent  of these toilets were either “dirty” or “very dirty”, and one in six facilities  was completely non-functional. Households who were dissatisfied with the cleanliness of their community’s toilets were more likely  to practice open defecation, and almost 30 percent  of households reported doing so. Qualitative research suggests that these poor conditions may be caused by weak systems of accountability for toilet maintenance and repair.

Details of the Intervention:

This program sought to improve the physical infrastructure of community and public toilets, as well as to improve the associated management systems in order to ensure long-term maintenance. The physical infrastructure of a set of existing community toilets and a smaller set of existing public toilets will be updated to ensure that all have an adequate number of gender-separated toilets and washbasins; sufficient lighting and ventilation; and enough water for all services. A set of new toilets will also be constructed to these standards. A randomly chosen subset of both the community and public toilets will also be given enhanced, infrastructure, such as a space for bathing. Half  of the improved community and public toilets, including both those with and without the enhanced infrastructure, will be randomly selected to be maintained by a private firm, while the remainder will be managed by the community according to a “constitution” that specifies responsibilities and rights.

In order to identify a solution that will produce the most attractive, sustainable and hygienic alternatives to open defecation for slum residents, researchers will test a variety of complementary household-level interventions, such as discount coupons for shared facilities and varying the pricing structure (monthly passes vs. pay-per-use). Researchers will also conduct a program of demand generation activities in a subset of communities around community and public facilities. These activities will be used to help communities notice the problems associated with open defecation and develop community cohesion to sanction it.

Researchers will collect data to measure take-up and maintenance of sanitation facilities over the life of the program. Household surveys will be used to examine satisfaction with the facilities, instances of diarrheal disease, and differential access within the household.

Results and Policy Lessons:

Project ongoing; results forthcoming.

Bolstering Coverage of Improved Sanitation in Bangladesh

Poor sanitation is estimated to cause 280,000 deaths per year worldwide, despite the existence of simple, effective solutions. Governments and major development institutions have dedicated substantial resources and attention to improving sanitation in developing countries, but there has been little rigorous research on how best to increase sanitation coverage. This evaluation in Bangladesh found that subsidies for hygienic latrines targeted to the poor substantially increased latrine coverage and reduced open defecation. However, a commonly used community-motivation model, did not increase adoption of hygienic latrines when implemented alone, nor did providing information and technical support to community members. Results also suggest that adoption of improved latrines spurred adoption among neighbors, suggesting improved sanitation triggers a virtuous cycle.

Policy Issue:

One billion people, or about 15 percent of the world’s population, currently practice open defecation, and another 1.5 billion do not have access to a hygienic latrine or toilet.1 In spite of the existence of simple, effective solutions, such as pour-flush latrines, poor sanitation is estimated to cause 280,000 deaths per year, and may also contribute to serious long-term health conditions.2 Given the scope of the problem, governments and major development institutions have devoted substantial resources to improving sanitation in developing countries.3 However, significant disagreement remains over how best to increase sanitation coverage. Is it more effective to focus on demand generation through information campaigns and behavior change programs, or should governments focus on directly providing toilets to schools or households? Or is it better to subsidize private investment in sanitation? Do subsidies hurt intrinsic motivation? Researchers investigated these questions in Bangladesh.

Context of the Evaluation:

This research was conducted in relatively dense rural areas of Tanore, a sub-district in northwest Bangladesh, the poorest region of the country. Although sanitation coverage has increased dramatically in rural Bangladesh in recent decades, progress in Tanore has been slower. Prior to the start of the study, 31 percent of households reported that they either lacked a latrine or used an unimproved latrine. Only 50 percent had regular access to an improved sanitation facility, defined as a toilet or latrine that separates human excreta from human contact.

Details of the Intervention:

Researchers partnered with WaterAid Bangladesh and Village Education Resource Center to measure the impact of different policies designed to increase community-level latrine coverage on actual latrine coverage, investment in hygienic latrines, and the prevalence of open defecation. This research also aimed to provide insight into the household- and community-level behavioral mechanisms driving any effects.

Researchers randomly assigned 380 neighborhood communities, which included 18,254 households, to one of four groups:

1) Latrine Promotion Program (LPP) – Communities were invited to participate in a multi-day, neighborhood-level exercise to raise awareness of the problems caused by poor sanitation, and to motivate the community to increase coverage of hygienic latrines. The design of LPP followed that of Community-Led Total Sanitation, which focuses on behavioral change and community mobilization in eliminating open defecation. The approach has been implemented in over 60 countries worldwide.

2) LPP combined with subsidies – Communities were invited to participate in LPP and households were randomly selected via a public lottery to receive discount vouchers for the purchase of hygienic latrines. The vouchers provided a 75 percent discount on any of three available models of latrine, priced (after subsidy) US$5.5, US$6.5 and US$12. Households were responsible for delivery and installation costs of US$7-10. The richest 25 percent of households were not eligible for vouchers.

3) Information and technical support – “Latrine Sales Agents” were hired and trained from these communities and linked to local masons that built latrines. The agents acted as a resource for community members and also offered technical support for latrine installation.

4) Comparison group - No intervention

Results and Policy Lessons:

Adoption of latrines: Community motivation alone (LPP only) did not significantly increase adoption of hygienic latrines or reduce open defection relative to the comparison group. Providing information and technical support to community members also had no impact on adoption of latrines or open defecation.

However, LPP combined with the subsidy had substantial effects, increasing latrine coverage by 22 percentage points  among subsidized households and 8.5 percentage points among their unsubsidized neighbors, for an average village increase of 29-36 percent (14-15 percentage point), relative to villages where no subsidies were offered.  

Open defecation: Community motivation (LPP-only) did not significantly reduce open defection, nor did information and technical support. However, adding subsidies to LPP reduced open defection rates by 9 percentage points among adults in villages that received subsidies (including households that did not receive subsidies), representing a 22 percent reduction relative to the comparison group.

Social multipliers: A household was more likely to use the subsidy voucher to invest in a latrine if a larger share of their neighbors also received vouchers. A voucher winner in a neighborhood with medium coverage was 7 percentage points more likely to own a hygienic latrine than a voucher winner in a low coverage neighborhood, and 21 percentage points more likely to own a hygienic latrine relative to households in LPP-only neighborhoods. There was no detectable difference in hygienic latrine ownership between winners in neighborhoods with medium and high coverage.

Overall, these results are consistent with a growing body of research showing price is a primary barrier to adoption of health products. The results counter a commonly held belief that community-based motivation is the most effective way to move households away from open defection and toward basic latrines. Finally, this study presents evidence of the importance of social influence, and the possibility of a virtuous cycle where adoption of improved latrines spurs further adoption. 

[1] WHO/UNICEF, “Progress on Drinking Water and Sanitation - 2014 Update”, tech. rep. (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, Luxembourg, 2014).

[2] E.g. A. Lin et al., The American Journal of Tropical Medicine and Hygiene 89, 130–137 (July 2013).

[3] For example, in 2012 UNICEF spent US$380 million on programs focused on water, sanitation, and hygiene for children, which it estimates helped 10.6 million people gain access to improved sanitation. The World Bank’s Water and Sanitation Program plans to direct US$200 million in government and private funds to improve sanitation for 50 million people during the 2011-2015 period. 

The Long-Term Indirect Impacts of Early Childhood Deworming

Intestinal worm infections are among the world’s most widespread diseases, with roughly one in four people infected worldwide. Research has shown that when children are treated with deworming medication, worm infections become less prevalent not only for children who received the medication, but for those who live in the same environment as treated children. This evaluation tested whether a mass deworming campaign conducted among primary school pupils in western Kenya had long-term effects on young children who were in contact with treated children. It found large cognitive effects—equivalent to half a year of schooling—for children who were less than one year old when their communities received mass deworming treatment. For children with siblings in school at the time, improvements were twice as large.

Policy Issue:

Intestinal worm infections – including hookworm, whipworm, roundworm and schistosomiasis – are among the world’s most widespread diseases, with roughly one in four people infected worldwide. School-age children have the highest infection prevalence of any group, and while mild worm infections are often asymptomatic, more serious infections can lead to lethargy, anemia, and growth stunting. There is a growing body of evidence that suggests that school-based deworming can generate immediate improvements in child appetite, growth, and overall health, and subsequent improvements in school attendance. However, no evidence to date has shown whether deworming during early childhood can have lasting benefits. This research attempts to help fill this gap, providing the first evidence on the long-term effects of reducing helminth infection in early childhood.

Context of the Evaluation:

Between 1998 and 2001, researchers Edward Miguel and Michael Kremer carried out the Primary School Deworming Project (PSDP) in which they randomly phased in deworming drugs to a group of 75 primary schools in western Kenya. Children in this region suffered from high rates of worm infection before the study; 92 percent of children had at least one type of worm infection. The PSDP led to reduced infections, reduced anemia, and increased school attendance. While only schoolchildren were dewormed, the study found large “spillover” effects within the community. In terms of school attendance, for example, children in dewormed areas who were not actually given medication still received nearly 60 percent of the benefits of direct deworming.

This research took place in the same area as the PSDP, a densely populated farming regionin Samia and Bunyala districts, along the shores of Lake Victoria.

Details of the Intervention:

This study utilized the positive, indirect effects of the mass school-based deworming project, the Primary School Deworming Project,1 to estimate the long-term impact on young children whose communities were dewormed years earlier, but who did not receive medication directly.

The researcher utilized information from the original deworming project to divide the children into groups based on their age at the time deworming occurred in their communities. Because the project was implemented in phases from 1998 to 2001, children who were the same age in 2009 were different ages when deworming project took place. The researcher was therefore able to compare children whose communities were dewormed by the time they reached age 1 to those who were two years old or older (the comparison group) at the time the deworming project took place in their communities.

In 2009 and 2010, an IPA field team in Kenya collected height, weight, and migration data from more than 20,000 children at all of the deworming project schools in Samia and Bunyala districts of Kenya’s Western Province who were between the ages of 8-14 in 2009. For a subset of approximately 2,400 children, the team also conducted detailed cognitive assessments, which tested memory, reasoning, verbal fluency and receptive vocabulary.

Results and Policy Lessons:

Overall, the indirect effects of deworming in early childhood (starting by age 1) yielded substantial improvements in cognitive performance, providing evidence that an inexpensive intervention can reap immense benefits for children in early childhood.

Cognitive function: Early community deworming treatment resulted in an improvement of varying magnitudes on several standardized cognitive outcomes, including a0.22-standard-deviation increase in nonverbal reasoning ability specifically, and an 0.2-standard-deviation increase in an index combining all cognitive measures more broadly, equivalent to half a year of schooling.The effect was similar for children whose communities were dewormed the year they were born and for those that were dewormed two years before their birth.  

The cognitive effects were twice as large for children with an older sibling likely to have received deworming medication directly.

These improvements are well beyond the cognitive benefits of direct deworming later in childhood, indicating that early childhood deworming is particularly useful and policy relevant; deworming early in life may serve as not only an effective investment in future cognitive ability, but an extremely cost-effective one.  (Deworming costs around $0.59 per pupil per year,2 and indirect positive impacts obviously carry no additional cost.)

Height and stunting: Early childhood deworming did not have any long-term effects on stunting or height, suggesting that extreme caloric deprivation was neither a central issue for this population, nor is it a condition deworming chiefly addresses.

[1] Miguel, E., and M. Kremer (2004): “Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities,” Econometrica, 72(1), 159–217.

[2] Baird, Sarah, Joan Hamory Hicks, Michael Kremer, and Edward Miguel. "Worms at Work: Public finance implications of a child health investment."University of California at Berkeley,-mimeo (2014).


Owen Ozier

WASH Benefits: The Effects of Water Quality, Sanitation, Handwashing, and Nutrition Interventions on Child Health, Growth, and Development in Rural Kenya

There is little evidence on whether existing water quality, sanitation, and hygiene (WASH) interventions lead to lasting improvements in children’s health, growth and development and whether nutrition programs are more effective when combined with WASH interventions. In Kenya, researchers are measuring the individual and combined effects of these interventions on child health, growth, and development in the first two years of life.

Policy Issue:

Diarrheal diseases are a leading cause of death for children in the developing world, killing 760,000 children under the age of five each year.1 Even when diarrheal episodes are not fatal, illness early in life can have long-term effects on child growth and development.2 3 Many cases of diarrhea can be prevented with good water quality and sanitation. However, conclusive evidence on the relative health benefits of water, sanitation, and hygiene (WASH) interventions is lacking. Furthermore, few studies have evaluated these interventions in combination or measured health outcomes objectively; most research has relied reports from caregivers. To help fill this evidence gap, this evaluation aims to determine if WASH interventions aid in early child growth and development, if a combination of WASH interventions is more beneficial than a single intervention alone, and if improved nutrition is more beneficial when combined with WASH interventions. This study is related to an evaluation carried out by the International Center for Diarrheal Disease Research in Bangladesh.

Context of the Evaluation:

The study targets pregnant women and their newborn children in rural areas of Bungoma, Vihiga and Kakamega counties in western Kenya. Diarrhea prevalence is fairly high in these areas, and many households do not have good sanitation and hygiene practices. At baseline, 12 percent of children under three in study compounds suffered from diarrhea the previous week. Ninety-four percent of drinking water samples were contaminated with E. coli, only 17 percent of households had an improved latrine and only 2 percent of households had a potty to facilitate safe disposal of children’s feces (diapers are not commonly used), and only 2 percent of respondents had soap and water at a designated handwashing station.

Details of the Intervention:

Researchers are evaluating the individual and combined effects of various WASH and nutrition interventions on the health, growth and development of children in their first two years of life. The large-scale randomized evaluation is taking place among over 8,000 women and their newborns in rural areas of western Kenya.

Researchers randomly assigned participants, in clusters of 6-20 households, to one of eight groups:

1.)   Water quality: Chlorine dispensers were installed at communal water sources, and each household received 1 liter of bottled chlorine every six months. Local promoters visited households each month to encourage treating and safely storing drinking water, emphasizing how this could improve the health of children in the household.

2.)   Sanitation: Households received free child potties, “sani-scoops” to remove feces, and a new or upgraded pit latrine. Local promoters visited study compounds each month to encourage using latrines for defecation, removal of human and animal waste from the household area, and safe disposal of children’s feces.

3.)    Handwashing: Households received "dual tippy tap" stations for handwashing, with independent pedals attached to 5-liter jerry cans of clean water and jugs of soapy water. They were also provided with soap for the handwashing stations for the duration of the study. Local promoters visited study compounds monthly during the study to deliver messages on the importance of handwashing with soap.

4.)   Water Quality, Sanitation, and Handwashing:Households received all three WASH interventions.

5.)   Nutrition: Local promoters visited households to encourage exclusive breastfeeding for the first six months after birth and appropriate complementary feeding thereafter. From 6-24 months households received a supply of lipid-based nutrient supplements (LNS), which are fortified products that contain vitamins, minerals, and fats, and are designed to prevent malnutrition.

6.)   Nutrition + Water, Sanitation, and Handwashing:Households received the three WASH interventions plus the nutrition intervention.

7.)   Active comparison group: Households did not receive any intervention. However, village-level promoters visited households to record the circumference of the child's arm (MUAC), a measurement that was also conducted for children in the other groups.

8.)  Passive comparison group: No intervention or household visits.

Researchers will use data from initial surveys and measurements, as well as follow-up surveys conducted one and two years after the interventions began to evaluate the impact of the interventions on physical, cognitive, and socio-emotional growth and development. Outcomes of interest include diarrhea prevalence, indicators of compromised immune systems and gut function, parasitic infections, and physical growth, as well as motor skills, verbal skills, and socio-emotional abilities.

Results and Policy Lessons:

Results forthcoming.

[1] World Health Organization. “Diarrheal Disease.” Fact Sheet No. 330 April 2013.  Available at: http://www.who.int/mediacentre/factsheets/fs330/en/

[2] Crimmins EM, Finch CE, 2006. Infection, inflammation, height, and longevity. Proc Natl Acad Sci USA 103: 498–503.

[3] Prendergast, Andrew J., and Jean H. Humphrey. "The stunting syndrome in developing countries." Paediatrics and international child health 34, no. 4 (2014): 250-265.


Michael Kremer, Clair Null

Communication for Development in Ghana

A large number of child deaths in Sub-Saharan Africa are due to causes that are preventable through improved health behavior. In Ghana, researchers are evaluating the impact of a health communications program, which includes in-person, radio, and mobile phone interventions, on five key health behaviors.

Policy Issue:

Substantial progress has been made worldwide in reducing child deaths over the last 25 years, yet on average 17,000 children under five still die every day, mostly from preventable causes and treatable diseases.1 Sub-Saharan Africa has the highest child mortality rate relative to other regions—92 deaths per 1,000 live births. The leading causes of death among children are preterm birth complications, pneumonia, complications during labor and delivery, diarrhea, and malaria.  Promoting positive health behaviors through communications campaigns, including home visits by community health workers and radio broadcasts, may increase demand for services and products that can reduce the risk of preventable disease and death, such as antimalarial bed nets and oral rehydration salts. Moreover, given the growth of mobile phone ownership in the past decade, and evidence that individuals respond to mobile phone message reminders, text messages may serve as a cost-effective way to deliver key health messages and change behavior. This research in Ghana aims to shed light on these topics.

Context of the Evaluation:

Infectious diseases and malnutrition are major public health problems in Ghana. In 2008, 14 percent of children under five were underweight and 28 percent were stunted, and  malaria was the leading cause of death nationwide. In response, UNICEF and the Ghana Health Services, an agency within the Ministry of Health, launched the Communication for Development (C4D) program in March 2012 to increase awareness of common health problems in Ghana and reduce the risk of diseases and death, particularly for children under five.

Details of the Intervention:

Researchers are conducting a randomized evaluation to measure the impact of the basic C4D program and an expanded version with a mobile phone component (M4D) on five key behaviors:

1.     Exclusive breastfeeding for the first six months of life

2.     Hand washing with soap

3.     Sleeping under an insecticide-treated bed net to prevent malaria

4.     Treating diarrhea with oral rehydration solutions

5.     Using a skilled birth attendant

The basic C4D program promotes these behaviors through home visits and counseling by community-based agents (CBAs), radio broadcasts, and theater dramas. IPA partnered with VOTO mobile to develop and implement a mobile messaging component to complement the program, called Mobile for Development, or M4D. With M4D, mobile phone messages are sent to mothers of children under five to encourage the five health behaviors.

Of the 216 communities in the study, 108 were randomly assigned to receive various combinations of the interventions of the C4D program. Additionally, 2,380 households with cell phones were enrolled in the M4D sub-study evaluating the impact of voice messages sent to mobile phones. Mothers receive a total of 15 unique messages on the five key behaviors.

IPA is collecting data from approximately 20 households in each of the 216 communities, or approximately 4,269 households total. Researchers will measure the program’s impact on awareness, knowledge, behavior change, and continuous use across the five behaviors.

Results and Policy Lessons:

Results forthcoming.

[1]UNICEF, “Level and Trends in Child Mortality.” Report 2014. Retrieved March 11, 2015: http://data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/Child_Mortality_Report_2014_195.pdf


Aflatoxin Exposure and Child Stunting in Kenya

Child stunting has been associated with exposure to aflatoxin, a toxin produced by a fungus that affects crops such as maize, groundnuts, and sorghum. However, the causal relationship between aflatoxin exposure and height-for-age child growth has not been demonstrated.  This project seeks to reduce exposure of aflatoxin through a maize-testing and swapping program, while assessing the effects of post-harvest and storage technologies, which may reduce aflatoxin contamination in home-produced maize.

Policy Issue:

Aflatoxin is a toxin produced by the Aspergillus species of fungus. It is present in a variety of crops and animal products, though the consumption of maize and groundnuts is the most common source of exposure worldwide. Chronic consumption can cause cancer of the liver, and consumption in large quantities may cause aflatoxicosis, which is fatal. What is not known is the impacts of chronic exposure on child growth.  While a few studies have found some association between aflatoxin exposure and child stunting, these studies were not randomized evaluations and results remain inconclusive. This research aims, therefore, to provide rigorous evidence on the causal relationship between aflatoxin exposure and child growth.

Context of the Evaluation:

While developed countries have largely removed the risk of aflatoxin contamination from the human food supply through the use of modern drying and storage systems and routine testing, exposure remains a risk in many developing countries where maize is the staple food.  More than 1.2 billion people in Sub-Saharan Africa and Latin America rely on maize as a staple crop. In Kenya, maize is the staple for 96 percent of the country’s 40 million people, 1 and is the primary source of aflatoxin exposure.

This project is taking place in Meru and Tharaka-Nithi counties in eastern Kenya. High levels of both child stunting and aflatoxin exposure have been found in this region making it an appropriate site to study whether reducing aflatoxin exposure will improve child growth.

Details of the Intervention:

This project attempts to removed aflatoxin-contaminated maize from the diet of young children in eastern Kenya and evaluates the impact that reduced exposure has on child growth. This project also identifies and promotes improved post-harvest and storage technologies and evaluates the impact on aflatoxin contamination of smallholder farmers’ maize. The study is taking place across 71 villages in Meru County and Tharaka-Nithi county in eastern Kenya.

The villages are randomly assigned to one of two treatment groups or a comparison group. The first treatment group is designed to examine the effects of improved post-harvest and storage practices on aflatoxin levels in maize stores. Households in this group will receive intensive training regarding the hazards of aflatoxin consumption, how maize and other crops become infected with aflatoxin, and which storage and post-harvest techniques can reduce aflatoxin levels in their food stores.2 Farmers in these households will also be given access to significantly discounted improved maize drying and storage equipment throughout the harvest season.

The second treatment group is designed to examine whether aflatoxin exposure impacts height-for-age child growth. Households in this group will be able to buy certified aflatoxin-safe maize provided by the study via a local stockist.3 They will also be offered testing of their household maize stores at least every two months over a period of two years, and will be given the opportunity to switch out any aflatoxin-contaminated maize for aflatoxin-safe maize. The linear growth of children born during the study period in these households will be compared to growth of those in the comparison group. Blood samples and measurements are collected from pregnant mothers at baseline, while child blood sample and measurements will be collected during endline. Blood sera will be analyzed for a biomarker indicating recent exposure to aflatoxin.

At the conclusion of the intervention, study results will be reported back to all villages; the research team will provide information regarding the most successful post-harvest and storage techniques, as well as the cost of those techniques.

Results and Policy Lessons:

Results forthcoming.


[1]Liu, Y. and F. Wu. (2010). Global Burden of Aflatoxin-Induced Hepatocellular Carcinoma: A Risk Assessment. Environmental Health Perspectives. 118(6): 818–824.

[2]Given the known health effects of aflatoxin exposure, an intervention benefitting only a subset of study households would raise ethical issues. The research team is therefore providing information on how to reduce aflatoxin exposure to all study households, both those in the intervention group and those in the comparison group.

[3]Aflatoxin-safe maize is contaminated at a rate below 10ppb, the government-designated threshold safe for human consumption.

Vivian Hoffmann

The Zambian Early Childhood Development Project

Despite an increased international interest in child development, representative data on child development is still remarkably scarce, particularly from Sub-Saharan Africa. For this project, researchers from Harvard University and the University of Zambia partnered with the Zambian Ministry of Education, the Examination Council of Zambia and UNICEF to develop and evaluate a comprehensive instrument for assessing Zambian children’s physical, socio-emotional, and cognitive development before and throughout their schooling careers. The project has thus far demonstrated that comprehensive child assessments are feasible. Longer-term follow-studies are planned to assess both the validity of the tool and to identify the most important domains of child development for schooling outcomes in a Sub-Saharan African context.

Policy Issue:

Early childhood care and education remains underdeveloped in much of the developing world, though early educational experiences may have a significant impact on future learning. A large number of studies have investigated the impact of early childhood experiences on children’s developmental, health, and educational outcomes in developed countries, yet relatively little evidence is available on early childhood development in Sub-Saharan Africa. This research responds to this knowledge gap, aiming to improve understanding of child development in a Sub-Saharan Africa context.

Note: This study is not a randomized controlled trial.

Context of the Evaluation:

In 2009, the Zambian Ministry of Education, the Examination Council of Zambia, UNICEF, the University of Zambia, and the Center on the Developing Child at Harvard University launched the Zambian Early Childhood Development Project (ZECDP), a collaborative effort to measure child development in general, and to measure the improvements in child development achievable through large health programs like Zambia’s nationwide Rollback Malaria program. In order to comprehensively measure children’s development prior to school entry, the ZECDP created an instrument for assessing children’s physical, socio-emotional, and cognitive development before and throughout their schooling careers—the first assessment tool of its kind in Zambia.

Details of the Intervention:

Researchers and early childhood development stakeholders from the University of Zambia, the Ministry of Health, the Ministry of Education, and UNICEF developed and evaluated a comprehensive instrument for assessing Zambian children’s physical, socio-emotional, and cognitive development before they enter the formal schooling system.

Completed in May 2010, the Zambian Child Assessment Test (ZamCAT) combines existing child development measures with newly developed items in order to provide a broad assessment of children of preschool age in the Zambian context. The ZamCAT features tasks and tests to measure seven fundamental domains of child development: fine motor skills, language (expressive and receptive), non-verbal reasoning, information processing, executive functioning, socio-emotional development and task orientation.

After two rounds of piloting, a first cohort of 1,686 children born in 2004, from randomly selected households across 73, was assessed between July and December 2010. In 2011, successful follow-up occurred with 1,250 of those children. IPA collected data during an additional follow-up in June-August 2012. The 2012 survey covered 945 children and their caregivers in 53 of the study clusters. Trained surveyors visited the 945 randomly selected children and their caregivers at home, and conducted a one-hour long skill assessment with children followed by an one-hour interview with their caregiver to capture children’s socioeconomic and health background as well as children’s exposure to early learning programs.

Results and Policy Lessons:

Results from the ZECDP suggest a stark socioeconomic gradient in children’s development prior to entering school. In the absence of national preschool programs, only a relatively small fraction of Zambia children has access to early childhood care and learning prior to entering school, further increasing developmental differences generated by limited nutrition and exposure to infectious disease in the first years of children’s lives.

The research team plans to follow up with children from both the 2010 and 2012 cohort when they complete primary school to further validate the instrument and to identify the most critical aspects of child development in this context.

Read more about the Zambian Early Childhood Development Project in this UNICEF report.


Gunther Fink

The Role of Fees and Information in Healthcare Decisions in Mali

Globally, considerable progress has been made in the past decades in reducing the child mortality rate, yet very high rates remain in many countries, most of them in Sub-Saharan Africa. In this study, researchers are evaluating the effects of providing free health care and free health care workers to children of poor families in Mali. They are measuring how the two programs, coupled together and provided individually, influence use of preventive care, the use of formal medical care, and the amount of time caregivers wait before seeking care for a sick child.

Policy Issue:

Many countries have succeeded in reducing their child mortality rates over the past two decades. The number of children in developing countries who died before they reached the age of five dropped from 100 to 72 deaths per 1,000 live births between 1990 and 2008. Still, every year almost nine million children die before they reach their fifth birthday. Many of these children, 43 percent, died from pneumonia, diarrhea, malaria or AIDS, and more than a third of all child deaths were related to under-nutrition.

Policymakers and development organizations across the developing world have been striving to reduce the number of children that die before their fifth birthday by two-thirds by 2015, in accordance with the UN Millennium Development Goals. Not everyone agrees on the most effective, and most cost-effective ways to reach this goal, however, and much debate has surrounded the delivery and funding of primary healthcare for children. This study contributes much-needed evidence on what drives parents’ decisions about their children’s health care and the barriers they face in obtaining timely care for their children.

Context of the Evaluation:

Mali has shown considerable progress in addressing child mortality since 1990, essentially halving the proportion of children who die before the age of five. Despite this progress, health indicators in Mali remain poor, and infant mortality rates are still among the highest in the world, with 128 out of 1,000 children dying before age five.

The Mali Health Organizing Project (Mali Health), the implementing partner in this study, aims to improve health care quality and access for people living in impoverished areas of Bamako. Founded in 2007, Mali Health works to deliver cost-effective results through community-driven, culturally appropriate, and sustainable approaches. This study will help the organization assess how to provide quality health services at an affordable cost to poor populations.

Details of the intervention:

To evaluate the impact of providing health care workers and free health care to families in Mali on use of preventive care, use of formal medical care vs. traditional healers, and the amount of time families wait before seeking care when their child is acutely ill, researchers are carrying out a randomized evaluation among low-income households in Sikoroni, near urban Bamako. Researchers randomly assigned 1,050 similar households into one of four groups and Mali Health implemented the programs.

Healthcare worker only: Each family is assigned a locally recruited health worker, trained by Mali Health and employed full time. In biweekly visits, the health worker assesses the child's health according to a WHO-based protocol and advises the family if they should visit the clinic. The health workers also provide general information about good health practices and encourage preventive measures. These efforts focus on 13 Essential Family Practices as defined by the Malian government and include hand washing, bednet usage and water purification.

Free healthcare only: Healthcare at the two local clinics is free for the enrolled children if their illness is due to malnutrition, malaria, vaccine preventable diseases, diarrhea, or acute respiratory infection, and can be treated at the community clinic. The average cost per clinic visit that Mali Health currently reimburses is about CFA6000, or roughly US$12

Free healthcare and healthcare workers

No intervention- comparison group

Researchers collected detailed data on each child’s socio-economic background and used weekly visits over 7 to 10 weeks in two survey rounds in order to construct a complete health history detailing on a daily basis all symptoms that a child exhibited, and all healthcare sought by the family. Researchers are using data to pinpoint specific characteristics, identified during the initial survey period, that prevent families from seeking care, such as financial constraints, inability to borrow or save, insufficient information about health and healthcare, and/or different spending priorities.

Results and Policy Lessons: 

Results forthcoming.  


Mark Dean, Anja Sautmann

Harvesting Rainfall: Cistern Deployment in Northeast Brazil

What is the impact and cost-effectiveness of rain-fed water cisterns as a main source of water access in rural areas lacking other water sources? This project studies a 16,000 liter cistern for residential use which is filled during the rainy season, and – in theory – should provide families enough water for cooking and drinking during the dry season.

The technology is well developed, and the Brazilian government has been providing thousands of these cisterns to a target population of millions in northeast Brazil for the last 8 years. However, a rigorous randomized control trial of the adequacy of this technology and its impacts at the household level has not been performed up to now.

We have partnered with the local NGO building the cisterns (ASA) and the Brazilian Government (MDS), and obtained their support for a randomized control trial of their program. Funding for cistern-building has been obtained from the Spanish Development Agency in Brazil and the Brazilian Government.

Source Dispensers and Home Delivery of Chlorine in Kenya


Policy Issue: 

Diarrheal diseases are a leading cause of morbidity and mortality in the developing world, killing an estimated 2.6 million people per year between 1990 and 2000. Children under 5 experience an average of 3.2 diarrheal episodes per year1 and diarrheal diseases account for 20 percent of deaths in this age group.2  Even when diarrheal episodes are not fatal, they can have long-term impacts on children’s cognitive and physical development. Diarrheal diseases are often transmitted when a water supply is contaminated with fecal matter, and may be endemic in places where the water supply is irregular. Practices from handwashing to water source protection are proven to reduce diarrhea episodes, yet the adoption of such practices has been slow in regions across the developing world.

Context of the Evaluation: 

Despite widespread awareness of the dangers of drinking unsafe water, there is extremely low adoption of sanitation or clean water practices in rural Western Kenya. While three quarters of households have heard of point-of-use water chlorination and 70 percent admit that drinking dirty water causes diarrhea, only 5 percent of households report that their main drinking water supply is chlorinated. The most common method of water chlorination is through the individual purchase of chlorination products, which must be added to water at home. Community level chlorination has been considered as another strategy to increase chlorine take up. Much cheaper than individually packaged bottles, point-of-collection chlorine dispensers can be used at the sources where people collect their water. Here, social pressure may be maximized by making each individual’s sanitation choice publicly known.

Details of the Intervention: 

Researchers sought to examine the impact of factors including price, persuasion, promotion and the chlorination products themselves with a two-phase study. Prior to the study baseline surveys were administered to a random selection of households.

In the first phase, households were given seven WaterGuard bottles, an individual water treatment product, each sufficient for one month’s supply of clean water. They were also provided with improved drinking water storage pots with a tap to prevent contamination and detailed instructions on use. One third of this group received twelve coupons for a 50 percent discount on WaterGuard bottles, each valid for one month during the next year, and calendars with reminders. Another third received additional verbal persuasion messages beyond the basic WaterGuard instructions, and another third received no additional coupons or messages. To estimate social networking effects, the free WaterGuard bottles were distributed in different percentages in each community, allowing researchers to see if higher community levels of use increased individual adoption. A follow-up survey was administered between 2 and 7 months after the free WaterGuard was distributed.

In the second phase researchers compared six different treatments designed to increase WaterGuard adoption. For the first three treatments, scripted promotional messages were delivered at either the (1) household level, (2) community level, or (3) both. The second two treatments included repeated promotion of chlorination through a home visit by a community elected promoter. Despite volunteering to work for free, the promoter was paid either a (4) flat rate, or was (5) paid based on how many households had chlorinated water at follow-up visits. The last treatment (6) combined the incentivized promoter model with an unlimited supply of free WaterGuard delivered through a point-of-collection chlorine dispenser at the local water source. Follow-up surveys were conducted 3 weeks and 3-6 months after the start of the study.

Results and Policy Lessons: 

Impact of Free Home Distribution: Most households have a low willingness to pay for chlorine, despite its well known benefits. After receiving a free 7-month supply, chlorine was detected in 58 percent of households, much more than the 2 percent starting level. Still, only 10 percent of the distributed coupons were redeemed. Where WaterGuard bottles were distributed freely, additional persuasive messages had no effect on take up, and in retail markets they only had short-term effects. There appeared to be no “social networking” effects of living in a community with a higher level of chlorination, and no evidence was found that price was an effective screening mechanism to target households who are more likely to benefit from cleaner water.

Impact of Persuasion: Hiring local community members at a low wage to promote chlorine use among their neighbors is highly effective at increasing use. Chlorine was detected in 40 percent of households visited by a promoter, compared to only 4 percent in those who weren’t visited. Incentivizing these promoters had only modest effects. Communities with point-of-collection chlorine dispensers in combination with promoters saw 61percent of households chlorinate their water, up from only 2 percent prior to the study, suggesting that this is a highly cost-effective way to promote take up.

Scale-Up: Investments in marketing campaigns and coupon schemes proved to be ineffective strategies to encourage point-of-use chlorination. Free chlorination dispensed at water sources along with community promoters provided the most effective strategy to improve water cleanliness, potentially preventing diarrheal incidence in areas such as rural Kenya.


1 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531.

2 Parashar, Umesh, et al. “Global Illness and Deaths Caused by Rotavirus Disease in Children,” Emerging Infectious Diseases. Vol. 9. May, 2003.

Balwadi deworming in India

Policy Issue: 

Nearly 40% of children in Africa and Asia suffer from iron deficiency anemia (IDA), which can result in weakness, stunted physical growth, and a compromised immune system. Intestinal helminths (worms) cause chronic intestinal blood loss which contributes to iron deficiency anemia. Worms are prevalent among children in developing countries and are believed to have a negative impact on education, impacting child cognitive and physical development as well as school attendance. Estimates suggest that the impact of iron deficiency anemia—through both physical and cognitive channels—could be as large as 4% of GDP on average in less developed countries, yet there is little rigorous work by economists on the effects of anemia on economic development.

Context of the Evaluation: 

Like other developing nations in the region, iron deficiency anemia and Vitamin A deficiency affect many of India’s children. Over 69% of preschool aged children in urban Delhi are anemic and 30% suffer from intestinal worms, contributing to the high prevalence of malnutrition. In 2005, 46% of children were found to be underweight, and 38% were found to have stunted growth. Children in this study typically came from families of poor migrant laborers, and have a particularly high risk of anemia and other nutritional deficiencies.

Details of the Intervention: 

This study evaluated the impact of NGO Pratham’s preschool nutrition and health project in the slums of Delhi, India. The program delivered a package consisting of iron and Vitamin A supplementation and deworming drugs to 2-6 year old children through an existing preschool network.

Two hundred preschools with a total of 2,392 children were randomly divided into three treatment groups, which were gradually phased into the program over two years. The deworming drugs were taken at “health camps” held at the preschool approximately every three months. Preschool teachers in treatment schools were instructed to administer daily iron doses for thirty school days following each health camp. Children in both treatment and comparison groups were also administered Vitamin A supplements, which in addition to other health benefits, promotes the absorption of iron.

A household survey was administered to a random 30 percent of the child population from each preschool both at the baseline and then again before the final group was phased into the program. Hemoglobin (Hb) tests (to measure anemia) and parasitological tests (to measure the presence of worms) were administered in conjunction with the household survey. Child height and weight were measured during each health camp, and participation data was collected during monthly, unannounced visits to each preschool.

Results and Policy Lessons: 

Child Weight Gain: Large gains in child weight—roughly 0.5 kg on average—were found in the treatment schools relative to comparison schools over the two-year study period. No gains in average child height were found, but this pattern makes sense from a clinical standpoint: iron supplementation is thought to reduce acute malnutrition in the short-run by improving the absorption of micronutrients and increasing appetite, but improvements in chronic malnutrition are not expected over short periods.

Impact on School Attendance: Average preschool participation rates increased sharply by 5.8 percentage points among treated children, reducing preschool absenteeism by roughly one fifth.

Weight gains and school-participation improvements were most pronounced for sub-groups with high baseline anemia rates, in particular, for girls and children in low socioeconomic status areas.

Given the low cost of the intervention (averaging approximately US$1.70 per additional year of schooling induced for one child), these results suggest that the package of iron, Vitamin A and deworming drugs is a highly cost-effective means of improving child school participation and health in a poor urban setting where anemia and worm infections are widespread.

Edward Miguel

The Latrine Training Mat Project

In many countries, sanitation facilities, such as simple pit latrines are common and are helpful for maintaining sanitation and preventing illness. However, young children often continue to defecate in the open long after they are old enough to use the latrine finding open pit latrines intimidating and challenging to use. Innovations for Poverty Action has developed a simple, affordable, and scalable tool called the Safe Squat ™ latrine training mat for use in such contexts. Our training mat promotes good sanitation practices from an early age and fosters a life-long habit of latrine use by converting the latrine floor into a child-friendly, easy-to-clean surface.  The Latrine Training Mat Project has piloted several prototypes of the mat in rural Western Kenya with promising results and is currently working to pilot the tool in new locations. 

Policy Issue:

The World Health Organization estimates that 1.5 million children die each year from diarrheal disease.[1] Evidence demonstrates that families using latrines are less likely to have children with diarrhea than those who dispose of feces improperly, in the trash, or in the open near the household. .[2] However, access to a latrine is not enough to ensure safe disposal of children’s feces. Young children, particularly those under the age of five, often do not use latrines even when they have consistent access to one.[3]Latrines, often simple pits in the ground, can be difficult for young children to use, discouraging proper sanitation practices.

Evaluation Context:

Among world regions, Sub-Saharan Africa has the highest proportion of basic sanitation use, including open pit latrines (without a slab or platform), bucket latrines, hanging latrines, pour flush latrines that are not connected to a sewage system, and open defecation. Open pit latrines without a slab or platform can be particularly intimidating and challenging for children to use.  Based on a series of in-depth interviews with mothers in rural Western Kenya, IPA found that children defecate in the open long after they might be capable of using a latrine for two main reasons.  First, the hole of a pit latrine is often wide enough to frighten a small child, if not pose a serious safety risk.  Secondly, mothers are reluctant to promote latrine use for young children, since the messes they create make the latrine unpleasant for other families to use.  Ironically, frequent cleaning of the latrine floor can exacerbate the problem, as the size of the hole grows when the floor is scrubbed and the mud erodes away.

Description of the Intervention

IPA has designed a latrine training mat (LTM) called the Safe Squat ™  that is a flat, square slab made of plastic or treated wood, approximately 60 cm across with a tapered hole about 13cm wide at the center. It is elevated a few centimeters from the ground on risers and temporarily fits over the existing latrine hole.  The Safe Squat ™ training mat is designed to safely promote good sanitation practices from an early age, while saving mothers valuable time that might otherwise have been spent cleaning the latrine or disposing of feces.

IPA piloted the mat among two villages in Matungu District of Western Kenya.  Three prototypes were designed and tested among 12 households (six from each village). The prototypes were made of treated wood, temporary plastic, or permanent plastic, with the objective of determining the most acceptable material and design for the mat.  Both wooden and temporary plastic models were designed solely for children, and could be placed on and off the hole as needed. The permanent plastic mat was designed for the whole family to use, but the hole in the center of the mat was approximately 5 cm wider than the other two prototypes.  Data collected was qualitative in nature, consisting of in depth interviews and focus group discussions. This type of data collection assured a detailed and nuanced understanding of the participant’s experience with the latrine training mat. Following an in depth interview regarding her child’s defecation practices, mothers from each household received one of the three mat prototypes, and agreed to use the training mat with her child for at least one week. Researchers used the Trials of Improved Practice (TIP) methodology to assess whether the method of intervention delivery would influence the way in which the intervention was used and tested the intervention presentation in two ways.   In the first village, field officers merely explained that the mat was a sanitation tool to help young children use the latrine. In the second village, participants received the mat along with a detailed description of its main features, as well as explicit instructions on how the mat should be cleaned and stored.


Pilot Results:

The mat was well received by intervention participants in the Kenya based pilot.  The mothers that participated in the pilot reported that they liked the tool, and reported that it saved valuable time otherwise spent cleaning the latrine, or disposing of feces. They also reported that their children liked and used the mats regularly, and that other household members approved of the tool as well. Although pilot households preferred the permanent plastic mats for the whole family’s convenience, the temporary plastic mat remained the most acceptable choice for children under the age of five. There were no observed differences in mat use, between the village that received messaging, as opposed to the one that did not.  Based on these promising results, the Latrine Training Mat Project plans to conduct future pilots in new countries. If future pilots are successful, the Latrine Training Mat Project hopes to test the mats as part of a larger randomized controlled trial. 


[1]World Health Organization. “Diarrhoeal Disease” Fact Sheet No. 330. August 2009. Retrieved from www.who.int/mediacentre/factsheets/fs330/en/index.htmlon November 16, 2011.

[2]Mertens, T; Jaffar, S; Fernando, M.A; Cousens, S.N.; Feachem, R.G. Excreta disposal behavior and latrine ownership in relation to the risk of childhood diarrhea in Sri Lanka. International Journal of Epidemiology. 21 (6); 1157-1164, 1992.  


[3]Gil, A; Lanata, C; Kleinau, E; and Mary, P. Children's feces disposal practices

in developing countries and interventions to prevent diarrheal diseases: a literature review.

Environmental Health Project (EHP). 2004.


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