The Illusion of Sustainability
Last registered on August 02, 2016

Pre-Trial

Trial Information
General Information
Title
The Illusion of Sustainability
RCT ID
AEARCTR-0001084
Initial registration date
August 02, 2016
Last updated
August 02, 2016 6:25 PM EDT
Location(s)
Region
Primary Investigator
Affiliation
Center for Effective Global Action, University of California Berkeley
Other Primary Investigator(s)
PI Affiliation
UC Berkeley Department of Economics
PI Affiliation
Harvard University Department of Economics
Additional Trial Information
Status
Completed
Start date
1998-01-01
End date
2001-12-31
Secondary IDs
Abstract
We use a randomized evaluation of a Kenyan deworming program to estimate peer effects in technology adoption and to shed light on foreign aid donors’ movement towards sustainable community provision of public goods. Deworming is a public good since much of its social benefit comes through reduced disease
transmission. People were less likely to take deworming if their direct first-order or indirect second-order social contacts were exposed to deworming. Efforts to replace subsidies with sustainable worm control measures were ineffective: a drug cost-recovery program reduced take-up 80 percent; health education did not affect behavior, and a mobilization intervention failed. At least in this context, it appears unrealistic for a one-time intervention to generate sustainable voluntary local public goods provision.
External Link(s)
Registration Citation
Citation
Hicks, Joan, Michael Kremer and Edward Miguel. 2016. "The Illusion of Sustainability." AEA RCT Registry. August 02. https://www.socialscienceregistry.org/trials/1084/history/9898
Experimental Details
Interventions
Intervention(s)
In 1998, a local non-governmental organization (NGO) launched a program known as the Primary School Deworming Program (PSDP) to provide deworming medication to individuals enrolled in 75 primary schools in Busia District, a densely-settled farming region of rural western Kenya adjacent to Lake Victoria. The schools participating in the program consisted of nearly all rural primary schools in Budalangi and Funyula divisions in southern Busia district, and contained more than 30,000 pupils at the start of the study. Baseline parasitological surveys conducted by the Kenyan Ministry of Health indicated that these divisions had high rates of helminth infection at over 90%. Using modified WHO infection thresholds (Brooker et al., 2000b), roughly one-third of children in the sample had “moderate to heavy” infections with at least one helminth at the time of the baseline survey, a rate not atypical by regional standards (Brooker et al., 2000a). The 1998 Kenya DHS indicated that 85% of children in western Kenya, in the relevant age range of 8-18 years, were enrolled in school – suggesting that the sample was broadly representative of western Kenyan children as a whole at the time.

The 75 program schools were randomly divided into three groups (Groups 1, 2, and 3) of 25 schools each: the schools were stratified by geographical area (division, then zone), the zones were listed alphabetically (within each division), and then within each zone the schools were listed in increasing order of student enrolment, and every third school was assigned to a given project group. Due to the NGO’s administrative and financial constraints, the schools were phased into the program over the course of 1998-2001, and the order of phase-in was randomly determined, creating experimental treatment groups. Group 1 schools began receiving free deworming in 1998, Group 2 schools in 1999, while Group 3 schools began receiving the drugs in 2001. The project design implies that in 1998, Group 1 schools were treatment schools while Group 2 and 3 schools were the control, and in 1999 and 2000, Group 1 and 2 schools were the treatment schools and Group 3 schools the control, and so on. In 2002 all schools received free treatment. Children in Group 1 and 2 schools thus received two to three more years of deworming than Group 3 children. Deworming drugs were offered twice per year in treatment schools.

This study uses the Primary School Deworming Project (PSDP) to test several interventions including the following: social links, cost-sharing, health education, and verbal commitment.

Social links: Parent questionnaire respondents were asked for information on their closest social links: the five friends they speak with most frequently, the five relatives they speak with most frequently, additional social contacts whose children attend local primary schools, and individuals with whom they speak specifically about child health issues. These individuals are collectively referred to as the respondent’s direct “social links.” The survey also collected information on the deworming treatment status of social links’ children and the effects of treatment on their health, how frequently the respondent speaks with each social link, which primary schools links’ children attend, the global positioning system (GPS) location of the respondent’s home, and respondent’s knowledge of worm infections and attitudes toward deworming.

Cost-sharing: Between 1998 and 1999 PSDP delivered free deworming pills to 50 sample schools. In 2001, they were randomized again to assign half the schools to a cost-sharing intervention while the other half continued to receive free treatment. Two thirds of the schools participating in cost-sharing received albendazole at a cost of USD $0.40 per family, and one third received both albendazole and praziquantel (depending on the local prevalence of schistosomiasis) at a cost of USD $1.30 per family.

Health education: In addition to medication, all treatment schools received regular public health lectures, wall charts on worm prevention, and a full-day training session for two teachers from each school. The lectures and teacher training provided information on worm prevention behaviors—including washing hands before meals, wearing shoes, and not swimming in the lake.

Verbal commitment: A random subsample of pupils were asked whether they were planning to come to school on the next treatment day and whether the PSDP workers should bring pills for them on that day: 98 percent of children answered “yes” to both questions. All pupils interviewed—including both those offered the opportunity for verbal commitment and those not offered this opportunity—were provided the same information on the effects of deworming and the upcoming date of medical treatment.
Intervention Start Date
1998-03-01
Intervention End Date
2001-12-31
Primary Outcomes
Primary Outcomes (end points)
1. Drug take-up (measures effect of social links, cost-sharing, and verbal commitment) 2. Worm prevention behaviors (measures effect of health education)
Primary Outcomes (explanation)
Drug take-up: quantified by how many children took deworming drugs.

Worm prevention behavior: quantified through pupil cleanliness (of the hands and uniform) as observed by enumerators, the proportion of pupils observed wearing shoes, or self-reported exposure to fresh water.
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
In 1998, a local non-governmental organization (NGO) launched a program known as the Primary School Deworming Program (PSDP) to provide deworming medication to individuals enrolled in 75 primary schools in Busia District, a densely-settled farming region of rural western Kenya adjacent to Lake Victoria. The schools participating in the program consisted of nearly all rural primary schools in Budalangi and Funyula divisions in southern Busia district, and contained more than 30,000 pupils at the start of the study. The 75 program schools were randomly divided into three groups (Groups 1, 2, and 3) of 25 schools each: the schools were stratified by geographical area (division, then zone), the zones were listed alphabetically (within each division), and then within each zone the schools were listed in increasing order of student enrolment, and every third school was assigned to a given project group. Due to the NGO’s administrative and financial constraints, the schools were phased into the program over the course of 1998-2001, and the order of phase-in was randomly determined, creating experimental treatment groups. Group 1 schools began receiving free deworming in 1998, Group 2 schools in 1999, while Group 3 schools began receiving the drugs in 2001. The project design implies that in 1998, Group 1 schools were treatment schools while Group 2 and 3 schools were the control, and in 1999 and 2000, Group 1 and 2 schools were the treatment schools and Group 3 schools the control, and so on. In 2002 all schools received free treatment. Children in Group 1 and 2 schools thus received two to three more years of deworming than Group 3 children. Data was collected through pupil and parent questionnaires administered to randomly selected subsamples of students and parents in 2001.

Social links: The PSDP Parent Questionnaire was collected in 2001 during household visits among a representative subsample of parents with children currently enrolled in Group 2 and Group 3 schools.

Cost-sharing: Between 1998 and 1999 PSDP delivered free deworming pills to 50 sample schools in Groups 1 and 2. In 2001, they were randomized again to assign half the schools to a cost-sharing intervention while the other half continued to receive free treatment.

Health education: All treatment schools received health education.

Verbal commitment: A randomly selected subsample of pupils was given the verbal commitment intervention.
Experimental Design Details
Randomization Method
Computer random number generator.
Randomization Unit
Social links: school
Cost-sharing: school
Health education: school
Verbal commitment: pupil
Was the treatment clustered?
Yes
Experiment Characteristics
Sample size: planned number of clusters
Social links: 50 schools
Cost-sharing: 50 schools
Health education: 50 schools
Verbal commitment: not clustered
Sample size: planned number of observations
Social links: 1,678 parents Cost-sharing: 1,678 parents Health education: 9,102 pupils Verbal commitment: 3,164 pupils
Sample size (or number of clusters) by treatment arms
Social links: 25 treatment schools and 25 control schools
Cost-sharing: 25 treatment schools and 25 control schools
Health education: 25 treatment schools and 25 control schools
Verbal commitment: 1,582 treatment pupils and 1,582 control pupils
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
Study has received IRB approval. Details not available.
IRB Approval Date
Details not available
IRB Approval Number
Details not available
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
Yes
Intervention Completion Date
December 31, 2001, 12:00 AM +00:00
Is data collection complete?
Yes
Data Collection Completion Date
December 31, 2001, 12:00 AM +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
Social links: 50 schools
Cost-sharing: 50 schools
Health education: 50 schools
Verbal commitment: not clustered
Was attrition correlated with treatment status?
Final Sample Size: Total Number of Observations
Social links: 1,678 parents
Cost-sharing: 1,678 parents
Health education: 9,102 pupils
Verbal commitment: 3,164 pupils
Final Sample Size (or Number of Clusters) by Treatment Arms
Social links: 25 treatment schools and 25 control schools Cost-sharing: 25 treatment schools and 25 control schools Health education: 25 treatment schools and 25 control schools Verbal commitment: 1,582 treatment pupils and 1,582 control pupils
Reports and Papers
Preliminary Reports
Relevant Papers
Abstract
WORMS: IDENTIFYING IMPACTS ON EDUCATION AND HEALTH IN THE PRESENCE OF TREATMENT EXTERNALITIES

Intestinal helminths—including hookworm, roundworm, whipworm, and schistosomiasis—infect more than one-quarter of the world’s population. Studies in which medical treatment is randomized at the individual level potentially doubly underestimate the benefits of treatment, missing externality benefits to the comparison group from reduced disease transmission, and therefore also underestimating benefits for the treatment group. We evaluate a Kenyan project in which school-based mass treatment with deworming drugs was randomly phased into schools, rather than to individuals, allowing estimation of overall program effects. The program reduced school absenteeism in treatment schools by one-quarter, and was far cheaper than alternative ways of boosting school participation. Deworming substantially improved health and school participation among untreated children in both treatment schools and neighboring schools, and these externalities are large enough to justify fully subsidizing treatment. Yet we do not find evidence that deworming improved academic test scores.
Citation
Miguel, Edward, and Michael Kremer. 2004. "Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities." Econometrica 72(1): 159-217.
Abstract
THE ILLUSION OF SUSTAINABILITY

We use a randomized evaluation of a Kenyan deworming program to estimate peer effects in technology adoption and to shed light on foreign aid donors’ movement towards sustainable community provision of public goods. Deworming is a public good since much of its social benefit comes through reduced disease transmission. People were less likely to take deworming if their direct first-order or indirect second-order social contacts were exposed to deworming. Efforts to replace subsidies with sustainable worm control measures were ineffective: a drug cost-recovery program reduced take-up 80 percent; health education did not affect behavior, and a mobilization intervention failed. At least in this context, it appears unrealistic for a one-time intervention to generate sustainable voluntary local public goods provision.
Citation
: Kremer, Michael and Edward Miguel. 2007. "The Illusion of Sustainability." The Quarterly Journal of Economics122(3): 1007-65.