from EVIDENCE to POLICY Learning what works for better programs and policies March 2016 SENEGAL: Do Hygiene and Handwashing Make for Better Brain Development? Good hygiene practices play an important role in prevent- The World Bank works with governments to promote ing diarrhea and other infectious childhood diseases. Hand- improved sanitation, clean water and better hygiene practic- washing with soap and water—particularly after coming es, such as handwashing, all necessary to prevent the spread in contact with fecal of disease. Doing this successfully means understanding what WATER AND SANITATION matter or before han- works when it comes to campaigns to encourage people to dling food—can cut wash their hands, conduct proper hygiene management down on transmission within the household and what the impacts are on children’s of illnesses that sap health and development. In Senegal, researchers evaluated a children’s strength and program that focused on local media and community events development and hurt to encourage regular handwashing with soap and water. The their ability to thrive evaluation found that children’s socio-emotional develop- in school. Given the ment was improved in households with radios and televi- difficulties of improv- sions, but it wasn’t possible to separate out the effects of the ing handwashing rates, program being evaluated from a national media campaign especially in environ- promoting handwashing that was rolled out at the same time. ments where clean water may not be always available, un- While identifying the best routes for effective handwash- derstanding and measuring the impact on children’s brain ing and campaigns remains a key goal for researchers, this and body development can help build support for integrat- evaluation underscores the challenges of both changing ed water supply and hygiene programs. behavior and measuring impacts. Context Poor hygiene is a particular problem when it comes to children diarrheal disease are high. In Senegal, an estimated 23 percent of because they are more susceptible to diarrhea and repeated or se- people wash their hands after using the toilet and just 18 percent vere episodes can harm their health and development. Every year, after cleaning a baby’s bottom. Soap is usually far from the toilet 800,000 children under the age five die from diarrheal disease. or water source and most households do not have a specific place Recurrent episodes of diarrhea can also hurt a child’s ability to for handwashing. Senegal is one of the four countries targeted absorb nutrients and this can contribute to health problems and by the Global Scaling up Handwashing initiative, which uses in- physical and mental stunting. As a result, many governments and novative promotional campaigns to improve handwashing with organizations have created programs to encourage better hygiene soap and water among poor and vulnerable communities. The practices and handwashing with soap during critical times, such initiative, which is being implemented through the multi-donor as before eating and after using the toilet. These simple practices Water and Sanitation Program at the World Bank, has been have been proven to substantially reduce the spread of illnesses. rolled out in Peru, Senegal, Tanzania and Vietnam. Handwashing with soap at critical times isn’t common in The Government of Senegal, working with the Water and Senegal and other countries in sub-Saharan Africa and rates of Sanitation Program, launched a three-month national promo- tion campaign in 2009 that used mass media, including radio, out in seven of the country’s 11 regions. This ten-month pro- television, and billboards, to encourage people to wash their gram relied on community events to inform people about hand- hands with soap and water. In the campaign’s second phase, a washing and to influence their views and behavior to get them to more intensive, locally focused promotion campaign was rolled use soap and water regularly. Evaluation A randomized controlled trial was implemented to measure Once data had been collected, it became clear that peo- the impact of the second phase of the hygiene campaigns on ple in the control group had received information about children’s health and development. In the seven regions where handwashing through either the national media campaign the campaign was going to take place, 110 urban and rural or through parts of the local campaign or even from other villages were randomly selected and divided into 55 treat- households exposed to the campaign. It wasn’t possible to fig- WATER AND SANITATION ment and 55 control groups. The treatment group received ure out exactly through which campaign they had received the full campaign, which included handwashing promotional the information, but in the follow-up surveys it became clear advertisements through local media, community events and that the control group had been exposed to parts of one or direct meetings run through local women’s associations and both of the campaigns. At the same time, there was some in health clinics. The control group wasn’t supposed to re- question whether people in the treatment group had been af- ceive any part of the program fected by the local media campaign, or whether their infor- Researchers interviewed 1,150 households in these 110 mation came from the national campaign that was ongoing groups, focusing on women and other caregivers between the around the same time. ages of 14 and 49. The baseline survey was done in June- Given this “contamination,” researchers then conducted August 2009, before the local program was launched and the a quasi-experimental analysis of the survey data along with endline survey was done in early 2011. The surveyors con- government data from 2008 and 2011. The government data ducted face-to-face interviews, watched households’ hygiene created a large enough sample to match households with behaviors and collected stool samples. similar characteristics. This enabled them to compare the Children’s development was measured using the “Ages hygiene campaigns at different levels of intensity by compar- and Stages Questionnaire,” which screens for developmen- ing households with television and radio (high intensity) to tal milestones. The questionnaire covers a comprehensive list households with little to no access to television and radio (low of development indicators for children between four and 24 intensity). They assumed that television and radio facilitated months old that includes communication skills such as un- the delivery of the hygiene messages. The researchers avoided derstanding of commands or the ability to say basic words; bias by employing a matching technique to control for in- gross motor skills such as crawling or walking; and social- come, demographics, and other observable and unobservable personal skills such as smiling or expressing fear of strangers. differences between households. Results Children in households that were exposed to the Young children in households with television, radio, comput- local handwashing campaign and had access to ers or similar technologies generally showed greater improve- television and radio showed better socio-emotional ments in communication, gross motor, and socio-personal development, highlighting the importance of skills two years after the program, compared with children technology in getting across critical messages. in families without access to these technologies. This was re- This policy note is based on World Bank Policy Research Working Paper, “Can intense exposure to handwashing and hygiene information campaigns affect children’s socio- emotional skills? Evidence from Senegal,” Borja-Vega,Christian, Briceno,Bertha, Garcia Vicente,Fernando, November 5, 2015. http://documents.worldbank.org/curated/ en/2015/11/25247175/can-intense-exposure-hand-washing-hygiene-information-campaigns-affect-childrens-socio-emotional-skills-evidence-senegal gardless of whether the children were in households that were handwashing station had higher rates of diarrhea supposed to be in the treatment or control group. symptoms than those who lived in households with Children in households that didn’t have television, radio access to a place to wash hands with soap and water. or other technologies didn’t show any changes in socio-emo- tional scores, even if they lived in areas that were exposed Based on the survey data, one in ten children had diarrhea in to the local handwashing campaign. Researchers controlled the previous 14 days. The incidence of diarrhea among children for differences in wealth between the groups to make sure in Senegal appeared partly correlated to the presence or absence that this wasn’t because families with radios or televisions of a handwashing station and didn’t appear to be correlated may have had higher incomes and as a result might have been to income. Overall, families without access to a handwashing more receptive to sanitation messages. station with soap and water, or without access to an improved However, it’s possible that owning television or radio water source or improved sanitation spent more hours dealing might indicate that the family valued communication and with children’s illnesses and had slightly higher rates of ane- information and, as a result, their children might have had mia. But in general, many children in Senegalese households, better social and personal skills, apart from any hygiene infor- whether poor or not, have anemia. WATER AND SANITATION mation program they received. Thus, these results should be interpreted with caution. Television and radio broadcasting in Senegal have relatively When researchers looked solely at households in high coverage. Ownership of radio and TV is respectively areas where the local handwashing campaign took 87.2 percent and 40.1 percent. place, some skills critical for healthy development “Senegal: A Handwashing Behavior Change Jounrney,” World Bank 2010 improved, but only up to a point. As it turned out, children in the control and treatment groups weren’t the same at baseline, posing challenges to evaluat- It proved impossible to isolate the impact of ing the data. Infants in the control group—households that community-level activities from the impact of media weren’t supposed to receive the community-based handwash- campaigns. ing campaign—showed stronger communication skills before the program started. But children in households that received While the evaluation design sought to measure the impact of the full handwashing promotion program quickly caught up using local media and community events to inform people about in their communications skills. the importance of handwashing, it turned out that this campaign When it came to motor skills, the result was different. couldn’t be limited to just the villages in the treatment group. Again, young children in the control group had more ad- Households in different villages may have shared information, vanced motor skills at baseline and while this narrowed, chil- received information via the national media campaign, or local dren who started from a lower point never caught up. media wasn’t so local after all. Households that received the full local campaign, including media, community and direct meet- It wasn’t possible to measure if the campaign had ings, didn’t show any more knowledge of handwashing or any any impact on cognitive development. behavior change when compared with those who weren’t sup- posed to receive anything. There wasn’t any conclusive evidence that the hygiene infor- mation impacted children’s cognitive development, but some The evaluation offers a cautionary note to evidence suggested that children under age five in households researchers and governments alike. that had a television, a radio or both showed improvement in cognitive development. However, researchers pointed out this It’s difficult to test the impact of informational campaigns, could be because of the parents and how they stimulated the whether run together with other initiatives or not, because of children rather than any hygiene campaign. the ease with which media campaigns and information in gen- eral travels. At the same time, the presence of household media One thing was clear, even before the program and information technology may matter in how information was launched; children in households without a is transmitted or what other information people come across. During the survey to measure impact, it became Since multiple hygiene and sanitation campaigns were deliv- clear that many households had been exposed to ered to households and communities in both the treatment all parts of the campaign and it wasn’t possible to and comparison group over a short period of time, information evaluate or compare the impacts of different parts seemed to have passed between groups. This “contamination” of the campaign. across the studied groups made it impossible to pinpoint the impacts of two types of hygiene campaigns. Conclusion As the results of this impact evaluation indicate, radio and tele- change. The results of this evaluation can help guide develop- vision can be a successful route for transmitting messages and ment experts as they continue to examine ways to provide sani- WATER AND SANITATION having an impact on children’s development. Yet the poorest tation and hygiene for people who need it most. households, who often have the greatest need, are also less likely Future research may want to look at the cost effectiveness to have these access to technology. Indeed, getting information of mass media campaigns versus more intensive, personalized across to people– and then getting them to act on that informa- approaches, particularly for the poorest families, who may not tion—continues to be a key challenge faced by policymakers have radio, television or computers. Another thing to consid- across the globe. Identifying more channels to deliver infor- er is how to structure impact evaluations of such programs to mation and key hygiene messages to the poorest is important ensure that different groups aren’t able to share information, to improve the effectiveness of programs to induce behavior which makes it difficult to measure impact. The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development. THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Produced by the Strategic Impact Evaluation Fund Series Editor: Aliza Marcus Writer: Daphna Berman