Addressing the behavioural constraints to latrine uptake: effectiveness of a behaviour-change campaign in rural Cambodia
Claire Chase | Virginia Ziulu | Priya Lall | Phyrum Kov | Susanna Smets | Virak Chan | Yeng Lun
Cambodia has the lowest coverage of improved water and sanitation facilities in South-east Asia. Research suggests that rural Cambodians prefer a high-quality latrine over one provided for free. Market-based approaches are often used to increase sanitation coverage, but private operators lack sufficient incentives and resources to stimulate demand among households that are not immediately responsive to sales events. This study assessed the effectiveness of a Behaviour Change Communications (BCC) intervention designed to address behavioural factors that may limit uptake of latrines. The study applies a quasi-experimental matching technique to estimate the causal effect of the intervention on latrine uptake in rural areas. Communes that received both the BCC intervention and sanitation marketing were matched to similar communes where only sanitation marketing was carried out. Multivariate linear regression analysis is used to estimate the impact of the BCC intervention on latrine uptake. Results show that latrine uptake was slightly higher (0.55%) in BCC communes during the core period of the intervention, but wide variation in sales between communes made it difficult to detect a significant effect. Overall, coverage increased at a faster rate (3%) in BCC communes, but again, these results were not significant. Publicly subsidized sanitation promotion may help to reduce behavioural barriers to latrine adoption. In the absence of alternatives that address the financial constraints of households, such as toilet loans, or in situations where national policy discourages sanitation subsidies, government investment in BCC may be a worthwhile endeavour to strengthen parallel market development efforts, at least until sanitation businesses are well established.Dehejia, R.H. and Wahba, S. (2002) ‘Propensity score-matching methods for nonexperimental causal studies’, Review of Economics and Statistics 84 (1): 151–61 <http://dx.doi.org/10.3386/w6829>.
Devine, J. and Coombes, Y. (2009) ‘Introducing SaniFOAM: A framework to analyze sanitation behaviors to design effective sanitation programs’, Washington, DC: World Bank Water and Sanitation Program.
Gertler P., Shah, M., Alzua, M.L., Cameron, L., Martinez, S. and Patil, S. (2015) ‘How does health promotion work? Evidence from the dirty business of eliminating open defecation’, (NBER Working Paper No. 20997), Cambridge, MA: National Bureau of Economic Research <http://www.nber.org/papers/w20997> [accessed 1 September 2015].
Guerrant R.L., DeBoer, M.D., Moore, S.R., Scharf, R.J. and Lima, A.A.M. (2013) ‘The impoverished gut – a triple burden of diarrhoea, stunting and chronic disease’, Nature Reviews Gastroenterology & Hepatology 10 (4): 220–29 <http://dx.doi.org/10.1038/nrgastro.2012.239>.
Guiteras, R., Levinsohn, J. and Mobarak, A.M. (2015) ‘Encouraging sanitation investment in the developing world: a cluster-randomized trial’, Science 348 (6237): 903–06 <http://dx.doi.org/10.1126/science.aaa0491>.
Hlavac, M. (2014). Stargazer: LaTeX/HTML code and ASCII text for well-formatted regression and summary statistics tables. R package version 5.1. <http://CRAN.R-project.org/package=stargazer>.
Ho, D.E., Imai, K., King, G. and Stuart, E. (2011) ‘MatchIt: nonparametric preprocessing for parametric causal inference’, Journal of Statistical Software, 42 (8): 1–28 <http://www.jstatsoft.org/v42/i08/>.
Kov, P., Nguyen N.K. and Chan, V. (2015) Expanding Reach into Cambodia’s Rural Sanitation Market through Behavior Change Communication and Local Government Channels, Washington, DC: World Bank Water and Sanitation Program.
Pedi, D., Sophanna, M., Sophea, P. and Jenkins, M.W. (2014) Rural Consumer Sanitation Adoption Study: An Analysis of Rural Consumers in the Emerging Sanitation Market in Cambodia, Phnom Penh: WaterSHED <http://www.watershedasia.org/wp-content/uploads/2014/10/2014-10-RCSAS_lowres.pdf> [accessed 8 September 2015].
Prüss-Üstun, A., Bartram, J., Clasen T., Colford, J.M. Jr., Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of diarrheal disease from inadequate water, sanitation and hygiene in low- and middle-income countries: a retrospective analysis of data from 145 countries’, Tropical Medicine and International Health 19 (8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.
R Core Team (2014) R: A language and environment for statistical computing, Vienna: R Foundation for Statistical Computing <http://www.R-project.org/> [accessed 8 September 2015].
Rosenbaum, P.R. and Rubin, D.B. (1983) ‘The central role of the propensity score in observational studies for causal effects’, Biometrika 70 (1): 41–55.
WaterSHED-Asia (2012) Characteristics of Household Sanitation Use and Demand in CLTS and non-CLTS Villages: A Comparative Study from Rural Cambodia, Phnom Penh: WaterSHED-Asia.
World Health Organization (WHO) and UNICEF (2013) Progress on Drinking Water and Sanitation: 2013 Update, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
WHO and UNICEF (2015) Progress on Sanitation and Drinking Water: 2015 Update And MDG Assessment, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
World Bank (2015) ‘Synthesis report on technical assistance P132201: Cambodia sanitation marketing’, Washington, DC: World Bank Water and Sanitation Program <http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/04/30/090224b082e294f0/1_0/Rendered/PDF/Synthesis0repo0sanitation0marketing.pdf> [accessed 8 September 2015].
Dehejia, R.H. and Wahba, S. (2002) ‘Propensity score-matching methods for nonexperimental causal studies’, Review of Economics and Statistics 84 (1): 151–61 <http://dx.doi.org/10.3386/w6829>.
Devine, J. and Coombes, Y. (2009) ‘Introducing SaniFOAM: A framework to analyze sanitation behaviors to design effective sanitation programs’, Washington, DC: World Bank Water and Sanitation Program.
Gertler P., Shah, M., Alzua, M.L., Cameron, L., Martinez, S. and Patil, S. (2015) ‘How does health promotion work? Evidence from the dirty business of eliminating open defecation’, (NBER Working Paper No. 20997), Cambridge, MA: National Bureau of Economic Research <http://www.nber.org/papers/w20997> [accessed 1 September 2015].
Guerrant R.L., DeBoer, M.D., Moore, S.R., Scharf, R.J. and Lima, A.A.M. (2013) ‘The impoverished gut – a triple burden of diarrhoea, stunting and chronic disease’, Nature Reviews Gastroenterology & Hepatology 10 (4): 220–29 <http://dx.doi.org/10.1038/nrgastro.2012.239>.
Guiteras, R., Levinsohn, J. and Mobarak, A.M. (2015) ‘Encouraging sanitation investment in the developing world: a cluster-randomized trial’, Science 348 (6237): 903–06 <http://dx.doi.org/10.1126/science.aaa0491>.
Hlavac, M. (2014). Stargazer: LaTeX/HTML code and ASCII text for well-formatted regression and summary statistics tables. R package version 5.1. <http://CRAN.R-project.org/package=stargazer>.
Ho, D.E., Imai, K., King, G. and Stuart, E. (2011) ‘MatchIt: nonparametric preprocessing for parametric causal inference’, Journal of Statistical Software, 42 (8): 1–28 <http://www.jstatsoft.org/v42/i08/>.
Kov, P., Nguyen N.K. and Chan, V. (2015) Expanding Reach into Cambodia’s Rural Sanitation Market through Behavior Change Communication and Local Government Channels, Washington, DC: World Bank Water and Sanitation Program.
Pedi, D., Sophanna, M., Sophea, P. and Jenkins, M.W. (2014) Rural Consumer Sanitation Adoption Study: An Analysis of Rural Consumers in the Emerging Sanitation Market in Cambodia, Phnom Penh: WaterSHED <http://www.watershedasia.org/wp-content/uploads/2014/10/2014-10-RCSAS_lowres.pdf> [accessed 8 September 2015].
Prüss-Üstun, A., Bartram, J., Clasen T., Colford, J.M. Jr., Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of diarrheal disease from inadequate water, sanitation and hygiene in low- and middle-income countries: a retrospective analysis of data from 145 countries’, Tropical Medicine and International Health 19 (8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.
R Core Team (2014) R: A language and environment for statistical computing, Vienna: R Foundation for Statistical Computing <http://www.R-project.org/> [accessed 8 September 2015].
Rosenbaum, P.R. and Rubin, D.B. (1983) ‘The central role of the propensity score in observational studies for causal effects’, Biometrika 70 (1): 41–55.
WaterSHED-Asia (2012) Characteristics of Household Sanitation Use and Demand in CLTS and non-CLTS Villages: A Comparative Study from Rural Cambodia, Phnom Penh: WaterSHED-Asia.
World Health Organization (WHO) and UNICEF (2013) Progress on Drinking Water and Sanitation: 2013 Update, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
WHO and UNICEF (2015) Progress on Sanitation and Drinking Water: 2015 Update And MDG Assessment, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
World Bank (2015) ‘Synthesis report on technical assistance P132201: Cambodia sanitation marketing’, Washington, DC: World Bank Water and Sanitation Program <http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/04/30/090224b082e294f0/1_0/Rendered/PDF/Synthesis0repo0sanitation0marketing.pdf> [accessed 8 September 2015].
Dehejia, R.H. and Wahba, S. (2002) ‘Propensity score-matching methods for nonexperimental causal studies’, Review of Economics and Statistics 84 (1): 151–61 <http://dx.doi.org/10.3386/w6829>.
Devine, J. and Coombes, Y. (2009) ‘Introducing SaniFOAM: A framework to analyze sanitation behaviors to design effective sanitation programs’, Washington, DC: World Bank Water and Sanitation Program.
Gertler P., Shah, M., Alzua, M.L., Cameron, L., Martinez, S. and Patil, S. (2015) ‘How does health promotion work? Evidence from the dirty business of eliminating open defecation’, (NBER Working Paper No. 20997), Cambridge, MA: National Bureau of Economic Research <http://www.nber.org/papers/w20997> [accessed 1 September 2015].
Guerrant R.L., DeBoer, M.D., Moore, S.R., Scharf, R.J. and Lima, A.A.M. (2013) ‘The impoverished gut – a triple burden of diarrhoea, stunting and chronic disease’, Nature Reviews Gastroenterology & Hepatology 10 (4): 220–29 <http://dx.doi.org/10.1038/nrgastro.2012.239>.
Guiteras, R., Levinsohn, J. and Mobarak, A.M. (2015) ‘Encouraging sanitation investment in the developing world: a cluster-randomized trial’, Science 348 (6237): 903–06 <http://dx.doi.org/10.1126/science.aaa0491>.
Hlavac, M. (2014). Stargazer: LaTeX/HTML code and ASCII text for well-formatted regression and summary statistics tables. R package version 5.1. <http://CRAN.R-project.org/package=stargazer>.
Ho, D.E., Imai, K., King, G. and Stuart, E. (2011) ‘MatchIt: nonparametric preprocessing for parametric causal inference’, Journal of Statistical Software, 42 (8): 1–28 <http://www.jstatsoft.org/v42/i08/>.
Kov, P., Nguyen N.K. and Chan, V. (2015) Expanding Reach into Cambodia’s Rural Sanitation Market through Behavior Change Communication and Local Government Channels, Washington, DC: World Bank Water and Sanitation Program.
Pedi, D., Sophanna, M., Sophea, P. and Jenkins, M.W. (2014) Rural Consumer Sanitation Adoption Study: An Analysis of Rural Consumers in the Emerging Sanitation Market in Cambodia, Phnom Penh: WaterSHED <http://www.watershedasia.org/wp-content/uploads/2014/10/2014-10-RCSAS_lowres.pdf> [accessed 8 September 2015].
Prüss-Üstun, A., Bartram, J., Clasen T., Colford, J.M. Jr., Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of diarrheal disease from inadequate water, sanitation and hygiene in low- and middle-income countries: a retrospective analysis of data from 145 countries’, Tropical Medicine and International Health 19 (8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.
R Core Team (2014) R: A language and environment for statistical computing, Vienna: R Foundation for Statistical Computing <http://www.R-project.org/> [accessed 8 September 2015].
Rosenbaum, P.R. and Rubin, D.B. (1983) ‘The central role of the propensity score in observational studies for causal effects’, Biometrika 70 (1): 41–55.
WaterSHED-Asia (2012) Characteristics of Household Sanitation Use and Demand in CLTS and non-CLTS Villages: A Comparative Study from Rural Cambodia, Phnom Penh: WaterSHED-Asia.
World Health Organization (WHO) and UNICEF (2013) Progress on Drinking Water and Sanitation: 2013 Update, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
WHO and UNICEF (2015) Progress on Sanitation and Drinking Water: 2015 Update And MDG Assessment, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
World Bank (2015) ‘Synthesis report on technical assistance P132201: Cambodia sanitation marketing’, Washington, DC: World Bank Water and Sanitation Program <http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/04/30/090224b082e294f0/1_0/Rendered/PDF/Synthesis0repo0sanitation0marketing.pdf> [accessed 8 September 2015].
Dehejia, R.H. and Wahba, S. (2002) ‘Propensity score-matching methods for nonexperimental causal studies’, Review of Economics and Statistics 84 (1): 151–61 <http://dx.doi.org/10.3386/w6829>.
Devine, J. and Coombes, Y. (2009) ‘Introducing SaniFOAM: A framework to analyze sanitation behaviors to design effective sanitation programs’, Washington, DC: World Bank Water and Sanitation Program.
Gertler P., Shah, M., Alzua, M.L., Cameron, L., Martinez, S. and Patil, S. (2015) ‘How does health promotion work? Evidence from the dirty business of eliminating open defecation’, (NBER Working Paper No. 20997), Cambridge, MA: National Bureau of Economic Research <http://www.nber.org/papers/w20997> [accessed 1 September 2015].
Guerrant R.L., DeBoer, M.D., Moore, S.R., Scharf, R.J. and Lima, A.A.M. (2013) ‘The impoverished gut – a triple burden of diarrhoea, stunting and chronic disease’, Nature Reviews Gastroenterology & Hepatology 10 (4): 220–29 <http://dx.doi.org/10.1038/nrgastro.2012.239>.
Guiteras, R., Levinsohn, J. and Mobarak, A.M. (2015) ‘Encouraging sanitation investment in the developing world: a cluster-randomized trial’, Science 348 (6237): 903–06 <http://dx.doi.org/10.1126/science.aaa0491>.
Hlavac, M. (2014). Stargazer: LaTeX/HTML code and ASCII text for well-formatted regression and summary statistics tables. R package version 5.1. <http://CRAN.R-project.org/package=stargazer>.
Ho, D.E., Imai, K., King, G. and Stuart, E. (2011) ‘MatchIt: nonparametric preprocessing for parametric causal inference’, Journal of Statistical Software, 42 (8): 1–28 <http://www.jstatsoft.org/v42/i08/>.
Kov, P., Nguyen N.K. and Chan, V. (2015) Expanding Reach into Cambodia’s Rural Sanitation Market through Behavior Change Communication and Local Government Channels, Washington, DC: World Bank Water and Sanitation Program.
Pedi, D., Sophanna, M., Sophea, P. and Jenkins, M.W. (2014) Rural Consumer Sanitation Adoption Study: An Analysis of Rural Consumers in the Emerging Sanitation Market in Cambodia, Phnom Penh: WaterSHED <http://www.watershedasia.org/wp-content/uploads/2014/10/2014-10-RCSAS_lowres.pdf> [accessed 8 September 2015].
Prüss-Üstun, A., Bartram, J., Clasen T., Colford, J.M. Jr., Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of diarrheal disease from inadequate water, sanitation and hygiene in low- and middle-income countries: a retrospective analysis of data from 145 countries’, Tropical Medicine and International Health 19 (8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.
R Core Team (2014) R: A language and environment for statistical computing, Vienna: R Foundation for Statistical Computing <http://www.R-project.org/> [accessed 8 September 2015].
Rosenbaum, P.R. and Rubin, D.B. (1983) ‘The central role of the propensity score in observational studies for causal effects’, Biometrika 70 (1): 41–55.
WaterSHED-Asia (2012) Characteristics of Household Sanitation Use and Demand in CLTS and non-CLTS Villages: A Comparative Study from Rural Cambodia, Phnom Penh: WaterSHED-Asia.
World Health Organization (WHO) and UNICEF (2013) Progress on Drinking Water and Sanitation: 2013 Update, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
WHO and UNICEF (2015) Progress on Sanitation and Drinking Water: 2015 Update And MDG Assessment, Geneva and New York: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
World Bank (2015) ‘Synthesis report on technical assistance P132201: Cambodia sanitation marketing’, Washington, DC: World Bank Water and Sanitation Program <http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/04/30/090224b082e294f0/1_0/Rendered/PDF/Synthesis0repo0sanitation0marketing.pdf> [accessed 8 September 2015].
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