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.
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.
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.
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.
Do social networks matter for the adoption of new political communication technologies? We collect complete social network data for sixteen Ugandan villages where an innovative reporting mobile platform was recently introduced, and show robust evidence of peer effects on technology adoption. However, peer effects were not observed in all networks. We develop a formal model showing that while peer effects facilitate adoption of technologies with minimal externalities (like agricultural practices), it can be more difficult for innovations with significant positive externalities to spread through a network. Early adopters might exaggerate benefits, leading others to discount information about the technology’s value. Thus, peer effects are likely to emerge only where informal institutions support truthful communication. We show that the observable implications of our model are borne out in the data. These impediments to social diffusion might help explain the slow and varied uptake of new political communication technologies around the world.
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.
Nearly 2.5 million mothers and babies die each year from complications in the immediate period around childbirth. Nairobi, Kenya has among the highest maternal and neonatal mortality rates in the world. Mounting evidence suggests delivering in a facility is not enough to drive mortality reductions, with utilization of poor quality facilities and delays in receiving care the major contributors to continued poor outcomes (Lozano et al. 2011). In addition to delivering in well-equipped facilities, women must arrive at the facility and be attended to in time for complications to be effectively managed. The “three delays” model attributes poor outcomes to delays in: (i) seeking care; (ii) arriving at the facility for delivery; and (iii) receiving adequate treatment once at the facility (Thaddeus 1994). These delays are strongly associated with morbidity and mortality (Pacagnella et al. 2014).
Delays could occur for many reasons including the need to travel far distances, information gaps about when to seek care in labor, or because women are away from facilities (e.g., because of overcrowding). Our preliminary work in Nairobi suggested that delays could also be occurring because of behavioral barriers to effective decision making and planning around facility delivery. Nairobi offers a very large, complex set of highly heterogeneous maternity facility options. Previous work has highlighted how choice in this type of decision context can lead to deferring decisions (Tversky and Shafir, 1992). In our preliminary work, we found that decisions about where to deliver were often made very late in pregnancy. We hypothesized that decision-making delays could lead to poor birth planning, which has been shown to increase delays in seeking care. We designed a “precommitment transfer package” which bundles a labeled cash transfer and precommitment conditional transfer (see online Appendix Section I). This intervention was designed to help women deliver where they want and to reduce delays, both by relieving financial barriers to on-time arrival and by facilitating earlier and more deliberate planning and implementation of plans for delivery. In other work, we analyze the impact of the intervention on the quality of delivery care received.
Many patients in low-income countries express preferences for high-quality health care but often end up with low-quality providers. We conducted a randomized controlled trial with pregnant women in Nairobi, Kenya, to analyze whether cash transfers, enhanced with behavioral “nudges,” can help women deliver in facilities that are consistent with their preferences and are of higher quality. We tested two interventions. The first was a labeled cash transfer (LCT), which explained that the cash was to help women deliver where they wanted. The second was a cash transfer that combined labeling and a commitment by the recipient to deliver in a prespecified desired facility as a condition of receiving the final payment (L-CCT). The L-CCT improved patient-perceived quality of interpersonal care but not perceived technical quality of care. It also increased women’s likelihood of delivering in facilities that met standards for routine and emergency newborn care but not the likelihood of delivering in facilities that met standards for obstetric care. The LCT had fewer measured benefits. Women preferred facilities with high technical and interpersonal care quality, but these quality measures were often negatively correlated within facilities. Even with cash transfers, many women still used poor-quality facilities. A larger study is warranted to determine whether the L-CCT can improve maternal and newborn outcomes.
Background: Despite the continued high prevalence of faltering growth, height monitoring remains limited in many low- and middle-income countries.
Objective: The objective of this study was to test whether providing parents with information on their child’s height can improve children’s height and developmental outcomes.
Design: Villages in Chipata District, Zambia (n = 127), were randomly assigned with equal probability to 1 of 3 groups: home- based growth monitoring (HBGM), community-based growth monitoring including nutritional supplementation for children with stunted growth (CBGM+NS), and control. Primary study outcomes were individual height-for-age z score (HAZ) and overall child development assessed with the International Fetal and Newborn Growth Consortium for the 21st Century Neurodevelopment Assessment tool. Secondary outcomes were weight-for-age z score (WAZ), protein consumption, breastfeeding, and general dietary diversity.
Results: We enrolled a total of 547 children with a median age of 13 mo at baseline. Estimated mean difference (b) in HAZ was 0.127 (95% CI: 20.107, 0.361) for HBGM and 20.152 (95% CI: 20.341, 0.036) for CBGM+NS. HBGM had no impact on child development [b: 20.017 (95% CI: 20.133, 0.098)]; CBGM+NS reduced overall child development scores by 20.118 SD (95% CI: 20.230, 20.006 SD). Both interventions had larger positive ef- fects among children with stunted growth at baseline, with esti- mated interaction effects of 0.503 (95% CI: 0.160, 0.846) and 0.582 (95% CI: 0.134, 1.030) for CBGM+NS and HBGM, respec- tively. HBGM increased mean WAZ [b = 0.183 (95% CI: 0.037, 0.328)]. Both interventions improved parental reports of children’s protein intake.
Conclusions: The results from this trial suggest that growth monitoring has a limited effect on children’s height and development, despite improvements in self-reported feeding practices. HBGM had modest positive effects on children with stunted growth. Given its relatively low cost, this intervention may be a cost-effective tool for increasing parental efforts toward reducing children’s physical growth deficits.
IPA Zambia is pleased to share its second quarter bulletin of 2017. This bulletin features updates on our research projects on improving public services by improving staff allocation; trust, spontaneous clusters, and the growth of urban small- and medium-sized enterprises; and interpersonal communication to encourage use of the Maximum Diva Woman's Condom. This bulletin also highlights IPA Zambia's presentation of preliminary results from the Girls Negotiation study in early May.
Background: Rigorous evaluations of health sector interventions addressing intimate partner violence (IPV) in low- and middle-income countries are lacking. We aimed to assess whether an enhanced nurse-delivered intervention would reduce IPV and improve levels of safety planning behaviors, use of community resources, reproductive coercion, and mental quality of life.
Methods: We randomized 42 public health clinics in Mexico City to treatment or control arms. In treatment clinics, women received the nurse-delivered session (IPV screening, supportive referrals, health/safety risk assessments) at baseline (T1), and a booster counselling session after 3 months (T2). In control clinics, women received screening and a referral card from nurses. Surveys were conducted at T1, T2, and T3 (15 months from baseline). Our main outcome was past-year physical and sexual IPV. Intent-to-treat analyses were conducted via three-level random intercepts models to evaluate the interaction term for treatment status by time.
Results: Between April and October 2013, 950 women (480 in control clinics, 470 in treatment clinics) with recent IPV experiences enrolled in the study. While reductions in IPV were observed for both women enrolled in treatment (OR, 0.40; 95% CI, 0.28–0.55; P < 0.01) and control (OR, 0.51; 95% CI, 0.36–0.72; P < 0.01) clinics at T3 (July to December 2014), no significant treatment effects were observed (OR, 0.78; 95% CI, 0.49–1.24; P = 0.30). At T2 (July to December 2013), women in treatment clinics reported significant improvements, compared to women in control clinics, in mental quality of life (β, 1.45; 95% CI, 0.14–2.75; P = 0.03) and safety planning behaviors (β, 0.41; 95% CI, 0.02–0.79; P = 0.04).
Conclusion: While reductions in IPV levels were seen among women in both treatment and control clinics, the enhanced nurse intervention was no more effective in reducing IPV. The enhanced nursing intervention may offer short-term improvements in addressing safety planning and mental quality of life. Nurses can play a supportive role in assisting women with IPV experiences.
In Sierra Leone, 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 described in this brief offer promising insights into everyday issues that affect the lives of the poor in Sierra Leone.
In Liberia, 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 described in this brief offer promising insights into everyday issues that affect the lives of the Liberian poor.
Research on intrahousehold decision making often finds that fathers have more decision-making power than mothers, but mothers put more weight on children’s well-being. One policy response has been to try to shift decision-making power toward mothers, for example by making mothers the recipient of transfers aimed at improving children’s welfare (Lundberg, Pollak, and Wales 1997). However, changing decision making in the family is not always feasible or advisable. In such cases, the divergent preferences and decision making of parents suggest a trade-off when targeting policies to improve children’s well-being. On the one hand, fathers have more power to change household behavior in ways that help children. On the other hand, mothers might have a stronger desire to do so. This trade-off might be especially stark in developing countries where women have especially low bargaining power (Jayachandran 2015).
We study this trade-off in the context of classes that teach parents low-cost ways to improve child health. Our setting is Uganda. Many simple, inexpensive behaviors that promote child health such as boiling drinking water, exclusively breastfeeding newborns, spacing births, and using antimalarial bed nets have low take-up, and increasing their adoption could reduce child malnutrition and mortality (Bhutta et al. 2013). We compare village-level parenting classes for mothers, which were held over the course of a year and encouraged these health-promoting behaviors, to similar classes for fathers. For the reasons discussed above, it is ambiguous whether targeting the classes to mothers or fathers will be more effective. In addition to contributing to the literature on intrahousehold decision making, this paper is one of the first to rigorously study whether mothers’ and fathers’ knowledge have different
impacts on child health.
Background: Community health clubs are multi-session village-level gatherings led by trained facilitators and designed to promote healthy behaviours mainly related to water, sanitation, and hygiene. They have been implemented in several African and Asian countries but have never been evaluated rigorously. We aimed to evaluate the effect of two versions of the community health club model on child health and nutrition outcomes.
Methods: We did a cluster-randomised trial in Rusizi district, western Rwanda. We defined villages as clusters. We assessed villages for eligibility then randomly selected 150 for the study using a simple random sampling routine in Stata. We stratified villages by wealth index and by the proportion of children younger than 2 years with caregiverreported diarrhoea within the past 7 days. We randomly allocated these villages to three study groups: no intervention (control; n=50), eight community health club sessions (Lite intervention; n=50), or 20 community health club sessions (Classic intervention; n=50). Households in these villages were enrolled in 2013 for a baseline survey, then re-enrolled in 2015 for an endline survey. The primary outcome was caregiver-reported diarrhoea within the previous 7 days in children younger than 5 years. Analysis was by intention to treat and per protocol. This trial is registered with ClinicalTrials.gov, number NCT01836731.
Findings: At the baseline survey undertaken between May, 2013, and August, 2013, 8734 households with children younger than 5 years of age were enrolled. At the endline survey undertaken between Sept 21, 2015, and Dec 22, 2015, 7934 (91%) of the households were re-enrolled. Among children younger than 5 years, the prevalence of caregiver-reported diarrhoea in the previous 7 days was 514 (14%) of 3616 assigned the control, 453 (14%) of 3196 allocated the Lite intervention (prevalence ratio compared with control 0·97, 95% CI 0·81–1·16; p=0·74), and 495 (14%) of 3464 assigned the Classic intervention (prevalence ratio compared with control 0·99, 0·85–1·15; p=0·87).
Interpretation: Community health clubs, in this setting in western Rwanda, had no effect on caregiver-reported diarrhoea among children younger than 5 years. Our results question the value of implementing this intervention at scale for the aim of achieving health gains.