Individuals care about how they are perceived by others, and take visible actions to signal their type. This paper investigates social signaling in the context of childhood immunization in Sierra Leone. Despite high initial vaccine take-up, many parents do not complete the five immunizations that are required in a child’s first year of life. I introduce a durable signal - in the form of differently colored bracelets - which children receive upon vaccination, and implement a 22-month-long experiment in 120 public clinics. Informed by theory, the experimental design separately identifies social signaling from leading alternative mechanisms. In a first main finding, I show that individuals use signals to learn about others’ actions. Second, I find that the impact of signals varies significantly with the social desirability of the action. In particular, the signal has a weak effect when linked to a vaccine with low perceived benefits and a large, positive effect when linked to a vaccine with high perceived benefits. Of substantive policy importance, signals increase timely and complete vaccination at a cost of 1 USD per child, with effects persisting 12 months after the roll out. Finally, I structurally estimate a dynamic discrete-choice model to quantify the value of social signaling.

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November 21, 2018
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IPA Zambia is pleased to share its Q1-Q3 bulletin from 2018. This bulletin highlights IPA Zambia's participation in research dissemination and conference events, including the Evidence for Impact Symposium and the Third National Food and Nutrition Summit.

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Brief
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November 19, 2018
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Background: Helminth and protozoan infections affect >1 billion children globally. Improved water, sanitation, handwashing, and nutrition could be more sustainable control strategies for parasite infections than mass drug administration (MDA), while providing other quality of life benefits. Methods and Findings: We enrolled geographic clusters of pregnant women into a cluster-randomized controlled trial that tested six interventions: disinfecting drinking water(W), improved sanitation(S), handwashing with soap(H), combined WSH, improved nutrition(N), and combined WSHN. We assessed intervention effects on parasite infections by measuring Ascaris lumbricoides, Trichuris trichiura, hookworm, and Giardia duodenalis among individual children born to enrolled mothers and their older siblings (ClinicalTrials.gov NCT01704105). We collected stool specimens from 9077 total children in 622 clusters, including 2346 children in control, 1117 in water, 1160 in sanitation, 1141 in handwashing, 1064 in WSH, 1072 in nutrition, and 1177 in WSHN. In the control group, 23% of children were infected with Ascaris lumbricoides, 1% with Trichuris trichuria, 2% with hookworm and 39% with Giardia duodenalis. After two years of intervention exposure, Ascaris infection prevalence was 18% lower in the water treatment arm (95% confidence interval (CI) 0%, 33%), 22% lower in the WSH arm (CI 4%, 37%), and 22% lower in the WSHN arm (CI 4%, 36%) compared to control. Individual sanitation, handwashing, and nutrition did not significantly reduce Ascaris infection on their own, and integrating nutrition with WSH did not provide additional benefit. Trichuris and hookworm were rarely detected, resulting in imprecise effect estimates. No intervention reduced Giardia. Reanalysis of stool samples by quantitative polymerase chain reaction (qPCR) confirmed the reductions in Ascaris infections measured by microscopy in the WSH and WSHN groups. Lab technicians and data analysts were blinded to treatment assignment, but participants and sample collectors were not blinded. The trial was funded by the Bill & Melinda Gates Foundation and USAID. Conclusions: Our results suggest integration of improved water quality, sanitation, and handwashing could contribute to sustainable control strategies for Ascaris infections, particularly in similar settings with recent or ongoing deworming programs. Water treatment alone was similarly effective to integrated WSH, providing new evidence that drinking water should be given increased attention as a transmission pathway for Ascaris. Clinical trial registration ID #NCT01704105.

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Published Paper
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November 09, 2018
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In Rwanda, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work below offer promising insights into everyday issues that affect the lives of the Rwandan poor. 

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October 17, 2018

We evaluate the impact of a large-scale information and mobilization intervention designed to improve health service delivery in rural Uganda by increasing citizens’ ability to monitor and apply bottom-up pressure on underperforming health workers. Modeled closely on the landmark “Power to the People” study (Bjorkman and Svensson, 2009), the intervention was undertaken in 376 health centers in 16 districts and involved a three wave panel of more than 14,000 households. We find that while the intervention had a positive impact on treatment quality and patient satisfaction, it had no effect on utilization rates or health outcomes (including child mortality). We also find no evidence that the channel through which the intervention affected treatment quality was citizen monitoring. The results hold in a wide set of pre-specified subgroups and also when, via a factorial design, we break down the complex intervention into its two most important components. While our findings validate the power of information provision to change the behavior of frontline service providers, they cast doubt on the power of information to foster community monitoring or to generate improvements in health outcomes, at least in the short term.

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Working Paper
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October 05, 2018
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How do standard development programs compare to just giving people cash? In Rwanda, researchers conducted a randomized evaluation to shed light on this question. Villages were randomly assigned to one of four groups: they received either a USAID-funded, integrated WASH and nutrition program (with savings and asset transfer components), unconditional cash grants of equal cost to the donor, a larger cash transfer, or no program at the time of study. The transfers were funded by USAID and Google.org.

The evaluation measured impacts on five main health and economic outcomes: household dietary diversity, maternal and child anemia, child growth (height-for-age, weight-for-age, and mid-upper arm circumference), household wealth, and household consumption, as well as other secondary outcomes, such as savings.

Key Findings:

After approximately one year:

»  The integrated nutrition and WASH program had a positive impact on savings, a secondary outcome, among the eligible population, but did not impact any primary outcomes (household dietary diversity, maternal or child anemia, child growth, household consumption, or wealth) within the period of the study.

»  An equivalent amount of cash (a cost to USAID of $142 per household) allowed households to pay down debt and boosted productive and consumption assets, but did not impact child health outcomes.

»  A much larger cash transfer—of more than $500 per household—had a wide range of benefits: it not only increased consumption, savings, assets, and house values,but improved household dietary diversity and height-for-age, and decreased child mortality.

»  The results suggest that, over the time period of the study, targeted programs focused on changing specific outcomes may be able to do so at lower cost than cash, but that large investments of cash can more rapidly affect some leading indicators of malnutrition.

»  The results also suggest that large cash transfers impact not only the economic measures of consumption and wealth, but also dietary diversity, height-for-age, and child mortality, while small transfers appear to have more limited benefits.

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September 18, 2018
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Maternal mortality remains very high in many parts of the developing world, especially in sub-Saharan Africa. Limited awareness of risk factors for maternal mortality such as maternal age and birth spacing may contribute to persistently high death rates, and public health campaigns to increase awareness of risk factors could help curb maternal mortality. Research shows that men, in particular, tend to underestimate maternal mortality risk, which may lead to their lower demand for contraception. Researchers worked in close collaboration with Zambia’s Ministry of Health and local NGOs to evaluate the impact of providing information to men and women about maternal mortality risk on knowledge of risk, demand for family planning, and maternal and child health outcomes. Preliminary results indicate that providing husbands with the information led to a reduction in fertility in the year that followed, while providing information to women had no comparable impact.

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July 30, 2018
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Key Findings:

  • Simple growth charts, which allowed parents to see if their child had a normal height for their age, did not reduce reduce growth deficits on average among the 547 children in the study, but among malnourished children, reduced stunting by 22 percentage points.
  • In contrast, inviting caregivers to quarterly meetings to learn if their children had a normal height and weight and providing food supplements to malnourished children had no impact on rates of stunting.
  • Neither home-based growth charts nor community-based monitoring were found to impact children’s cognitive development.
  • Home-based growth charts appear to be a cost-effective tool to reduce physical growth deficits in this context. For every dollar that was invested in growth charts, children who otherwise would have been stunted gained an estimated $16 in additional lifetime wages. 
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July 10, 2018

We present the results of a study designed to ‘benchmark’ a major USAID-funded child malnutrition program against what would have occurred if the cost of the program had simply been disbursed directly to beneficiaries to spend as they see fit. Using a three-armed trial from 248 villages in Rwanda, the study measures impacts on households containing poor or underweight children, or pregnant or lactating women, as well as the broader population of study villages. We find that the bundled health program delivers benefits in an outcome directly targeted by specific sub-components of the intervention (savings), but does not improve household dietary diversity, child anthropometrics, or anemia within the year of the study. A cost-equivalent cash transfer boosts productive asset investment and allows households to pay down debt. The bundled program is significantly better in cost-equivalent terms at generating savings and worse for debt reduction, while cost-equivalent cash drives more asset investment. A much larger cash transfer of more than $500 per household improves a wide range of consumption measures including dietary diversity, as well as savings, assets, and housing values. Only the large cash transfer shows evidence of moving child outcomes, with significant but modest improvements in child height-for-age, weight-for-age, and mid upper-arm circumference (about 0.1 SD). The results indicate that programs targeted towards driving specific outcomes can do so at lower cost than cash, but large cash transfers drive substantial benefits across a wide range of impacts, including many of those targeted by the more tailored program.

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Working Paper
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June 15, 2018
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This document provides a brief overview of the policies and best practices for ensuring the safe and ethical conduct of violence research at IPA. It also articulates the specific roles and responsibilities of IPA and its academic partners with respect to violence research. It is intended for principal investigators and research staff at IPA who are already familiar with the ethics of human subjects research, but are interested in more specific guidance related to the collection of violence data.

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Research Resource
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June 13, 2018
English

Innovations for Poverty Action (IPA) is a research and policy non-profit that discovers and promotes effective solutions to global poverty problems. IPA brings together researchers and decision-makers to design, rigorously evaluate, and refine these solutions and their applications, ensuring that the evidence created is used to improve the lives of the world’s poor. Since our founding in 2002, IPA has worked with over 575 leading academics to conduct over 650 evaluations in 51 countries. Future growth will be concentrated in focus countries, such as Myanmar, where we have local and international staff, established relationships with government, NGOs, and the private sector, and deep knowledge of local issues.

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February 20, 2018
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Background Poor nutrition and infectious diseases can prevent children from reaching their developmental potential. We aimed to assess the effects of improvements in water, sanitation, handwashing, and nutrition on early child development in rural Kenya.

Methods In this cluster-randomised controlled trial, we enrolled pregnant women in their second or third trimester from three counties (Kakamega, Bungoma, and Vihiga) in Kenya’s western region, with an average of 12 households per cluster. Groups of nine geographically adjacent clusters were block-randomised, using a random number generator, into the six intervention groups (including monthly visits to promote target behaviours), a passive control group (no visits), or a double-sized active control group (monthly household visits to measure child mid-upper arm circumference). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at year 1, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at year 2. Masking of participants was not possible, but data assessors were masked. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105.

Findings Between Nov 27, 2012, and May 21, 2014, 8246 women residing in 702 clusters were enrolled. No clusters were lost to follow-up, but 2212 households with 2279 children were lost to follow-up by year 2. 5791 (69%) children were measured at year 1 and 6107 (73%) at year 2. At year 1, compared with the active control group, the combined water, sanitation, handwashing, and nutrition group had greater rates of attaining the standing with assistance milestone (hazard ratio 1·23, 95% CI 1·09–1·40) and the walking with assistance milestone (1·32, 1·17–1·50), and the handwashing group had a greater rate of attaining the standing alone milestone (1·15, 1·01–1·31). There were no differences when comparing the other intervention groups with the active control group on any of the motor milestone measures at year 1. At year 2, there were no differences among groups for the communication, gross motor, personal social, or combined EASQ scores.

Interpretation The handwashing and combined water, sanitation, handwashing, and nutrition interventions might have improved child motor development after 1 year, although after 2 years there were no other differences between groups. Future research should examine ways to make community health and nutrition programmes more effective at supporting child development.

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February 12, 2018
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Background Poor nutrition and exposure to faecal contamination are associated with diarrhoea and growth faltering, both of which have long-term consequences for child health. We aimed to assess whether water, sanitation, handwashing, and nutrition interventions reduced diarrhoea or growth faltering.

Methods The WASH Benefits cluster-randomised trial enrolled pregnant women from villages in rural Kenya and evaluated outcomes at 1 year and 2 years of follow-up. Geographically-adjacent clusters were block-randomised to active control (household visits to measure mid-upper-arm circumference), passive control (data collection only), or compound-level interventions including household visits to promote target behaviours: drinking chlorinated water (water); safe sanitation consisting of disposing faeces in an improved latrine (sanitation); handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate maternal, infant, and young child feeding plus small-quantity lipid-based nutrient supplements from 6–24 months (nutrition); and combined water, sanitation, handwashing, and nutrition. Primary outcomes were caregiver-reported diarrhoea in the past 7 days and length-for-age Z score at year 2 in index children born to the enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105.

Findings Between Nov 27, 2012, and May 21, 2014, 8246 women in 702 clusters were enrolled and randomly assigned an intervention or control group. 1919 women were assigned to the active control group; 938 to passive control; 904 to water; 892 to sanitation; 917 to handwashing; 912 to combined water, sanitation, and handwashing; 843 to nutrition; and 921 to combined water, sanitation, handwashing, and nutrition. Data on diarrhoea at year 1 or year 2 were available for 6494 children and data on length-for-age Z score in year 2 were available for 6583 children (86% of living children were measured at year 2). Adherence indicators for sanitation, handwashing, and nutrition were more than 70% at year 1, handwashing fell to less than 25% at year 2, and for water was less than 45% at year 1 and less than 25% at year 2; combined groups were comparable to single groups. None of the interventions reduced diarrhoea prevalence compared with the active control. Compared with active control (length-for-age Z score –1·54) children in nutrition and combined water, sanitation, handwashing, and nutrition were taller by year 2 (mean difference 0·13 [95% CI 0·01–0·25] in the nutrition group; 0·16 [0·05–0·27] in the combined water, sanitation, handwashing, and nutrition group). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth.

Interpretation Behaviour change messaging combined with technologically simple interventions such as water treatment, household sanitation upgrades from unimproved to improved latrines, and handwashing stations did not reduce childhood diarrhoea or improve growth, even when adherence was at least as high as has been achieved by other programmes. Counselling and supplementation in the nutrition group and combined water, sanitation, handwashing, and nutrition interventions led to small growth benefits, but there was no advantage to integrating water, sanitation, and handwashing with nutrition. The interventions might have been more effcacious with higher adherence or in an environment with lower baseline sanitation coverage, especially in this context of high diarrhoea prevalence.

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January 29, 2018
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IPA Zambia is pleased to share its final bulletin from 2017. This bulletin features updates from our Saving for Safe Delivery study and the scale-ups of the food constraints and Catch Up projects. This bulletin also highlights IPA Zambia's dissemination events for the "Making Ghanaian Girls Great!" and "Interpersonal Communication to Encourage Use of Female Condoms in Zambia" studies.

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January 16, 2018

Preventing violence against women (VAW) requires witnesses to come forward, yet willingness to report is often undermined by social sanctions against those suspected of fabricating allegations. Our theory of the micro-politics of information disclosure in interdependent communities elucidates the role of social norms in preventing VAW. We present experimental evidence from a media campaign attended by over 10,000 Ugandans in 112 rural villages that featured three short videos designed to encourage reporting of VAW in the household. Results indicate a substantial reduction in VAW over a 6-month period following the campaign. Investigation of mechanisms reveals that women in the treatment group became less likely to believe that they would be labeled a gossip if they were to report an incident of VAW, and their personal willingness to speak out increased substantially. We find no evidence of a deeper change in core values pertaining to VAW.

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January 09, 2018

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