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Lancet Glob Health. 2018 Mar;6(3):e316-e329. doi: 10.1016/S2214-109X(18)30005-6. Epub 2018 Jan 29.

Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial.

Author information

1
Innovations for Poverty Action, Kakamega, Kenya; Center for International Policy Research and Evaluation, Mathematica Policy Research, Washington, DC, USA; Rollins School of Public Health, Emory University, Atlanta, GA, USA. Electronic address: cnull@mathematica-mpr.com.
2
Department of Nutrition, University of California, Davis, CA, USA.
3
Department of Civil and Environmental Engineering, Stanford University, Stanford, CA, USA; Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA.
4
Innovations for Poverty Action, Kakamega, Kenya; Department of Nutrition, University of California, Davis, CA, USA.
5
Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
6
Rollins School of Public Health, Emory University, Atlanta, GA, USA.
7
Division of Community Health Sciences, School of Public Health, University of California, Berkeley, CA, USA.
8
Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA.
9
Department of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.
10
Eastern and Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya.
11
Innovations for Poverty Action, Kakamega, Kenya.
12
Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA.

Abstract

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 efficacious with higher adherence or in an environment with lower baseline sanitation coverage, especially in this context of high diarrhoea prevalence.

FUNDING:

Bill & Melinda Gates Foundation, United States Agency for International Development.

PMID:
29396219
PMCID:
PMC5809717
DOI:
10.1016/S2214-109X(18)30005-6
[Indexed for MEDLINE]
Free PMC Article

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