Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial
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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.
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Evidence on the impact of improving household safe drinking water sources and/or treatment and storage, access to basic latrines and handwashing with soap on overall enteric pathogen detection and diarrhoea in children under 2 years of age is mixed, with some rigorously controlled and well-powered trials of interventions reporting little impact, even with high levels of behavioural compliance.
“Evidence on impact of improving household safe drinking water sources and/or treatment and storage, access to basic latrines and handwashing with soap on overall enteric pathogen detection and diarrhoea in children under 2 years of age is mixed, with some rigorously controlled and well-powered trials of interventions reporting little impact, even with high levels of behavioural compliance.1 6 7”
From Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study (2022) · cites this paper as [6]
The Results report no significant reduction in childhood diarrhoea with the water, sanitation, or handwashing interventions, and the Discussion contrasts this with trials that found protective effects. But the Discussion describes pathogen testing as a future use of stored stool specimens, not a reported result on enteric pathogen detection. It also notes that adherence to water and handwashing declined late in the trial, so the claim of high behavioural compliance needs qualification. (LLM, conf=0.88)
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Goddard, F. G. B., Ban, R., Barr, D. B., Brown, J. M., Cannon, J. L., Colford, J. M., Eisenberg, J. N. S., Ercümen, A., Petach, H., Freeman, M. C., et al. (2020) · Environmental Science & Technology · doi:10.1021/acs.est.0c02421 · Cited by 68 · see citing works
Self-citationStewart, C. P., Wessells, K. R., Arnold, C. D., Huybregts, L., Ashorn, P., Becquey, E., Humphrey, J. H., & Dewey, K. G. (2019) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqz262 · Cited by 69 · see citing works
Self-citationStewart, C. P., Dewey, K. G., Lin, A., Pickering, A. J., Byrd, K. A., Jannat, K., Ali, S., Rao, G., Dentz, H. N., Kiprotich, M., et al. (2018) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqy239 · Cited by 68 · see citing works
Self-citationSahiledengle, B., Petrucka, P. M., Kumie, A., Mwanri, L., Beressa, G., Atlaw, D., Tekalegn, Y., Zenbaba, D., Desta, F., & Agho, K. (2022) · BMC Public Health · doi:10.1186/s12889-022-14309-z · Cited by 63 · see citing works
Momberg, D. J., Ngandu, C. B., Voth‐Gaeddert, L. E., Ribeiro, K. C., May, J. D., Norris, S. A., & Mohamed, R. S. (2020) · Journal of Developmental Origins of Health and Disease · doi:10.1017/s2040174419000898 · Cited by 61 · see citing works
Leder, K. S., Openshaw, J. J., Allotey, P. A., Ansariadi, A., Barker, F., Burge, K., Clasen, T., Chown, S. L., Duffy, G. A., Faber, P. A., et al. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-042850 · Cited by 63 · see citing works
Self-citationShould the Randomistas (Continue to) Rule?
Ravallion, M. D. (2020) · Oxford University Press eBooks · doi:10.1093/oso/9780198865360.003.0003 · Cited by 62 · see citing works
Geere, J., & Hunter, P. R. (2019) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2019.08.007 · Cited by 64 · see citing works
Waddington, H. S., Masset, E., Bick, S., & Cairncross, S. (2023) · PLoS Medicine · doi:10.1371/journal.pmed.1004215 · Cited by 69 · see citing works
Adaptation of the small intestine to microbial enteropathogens in Zambian children with stunting
Amadi, B., Zyambo, K., Chandwe, K., Besa, E. C., Mulenga, C., Mwakamui, S., Siyumbwa, S. N., Croft, S., Banda, R., Chipunza, M., et al. (2021) · Nature Microbiology · doi:10.1038/s41564-020-00849-w · Cited by 60 · see citing works
Smuts, C. M., Matsungo, T. M., Malan, L., Kruger, H. S., Rothman, M., Kvalsvig, J. D., Covic, N. M., Joosten, K., Osendarp, S. J. M., Bruins, M. J., et al. (2018) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqy282 · Cited by 59 · see citing works
All Children Thrive: Integration of Nutrition and Early Childhood Development
Black, M. M., Trude, A. C. B., & Lutter, C. K. (2020) · Annual Review of Nutrition · doi:10.1146/annurev-nutr-120219-023757 · Cited by 63 · see citing works
Colston, J. M., François, R., Pisanic, N., Yori, P. P., McCormick, B., Olórtegui, M. P., Gazi, M. A., Svensen, E., Ahmed, M. M. M., Mduma, E. R., et al. (2019) · The Journal of Infectious Diseases · doi:10.1093/infdis/jiz072 · Cited by 56 · see citing works
Goddard, F. G. B., Pickering, A. J., Ercümen, A., Brown, J. M., Chang, H. H., & Clasen, T. (2020) · The Lancet Planetary Health · doi:10.1016/s2542-5196(20)30195-9 · Cited by 61 · see citing works
Self-citationReese, H., Routray, P., Torondel, B., Sinharoy, S. S., Mishra, S., Freeman, M. C., Chang, H. H., & Clasen, T. (2019) · International Journal of Epidemiology · doi:10.1093/ije/dyz157 · Cited by 57 · see citing works
Self-citationBekele, T., Rahman, B., & Rawstorne, P. (2020) · PLoS ONE · doi:10.1371/journal.pone.0239313 · Cited by 56 · see citing works
Lappan, R. J., Henry, R., Chown, S. L., Luby, S. P., Higginson, E. E., Bata, L., Jirapanjawat, T., Schang, C., Openshaw, J. J., O’Toole, J., et al. (2021) · The Lancet Planetary Health · doi:10.1016/s2542-5196(21)00051-6 · Cited by 56 · see citing works
Self-citationDrivers of stunting reduction in Nepal: a country case study
Conway-Moore, K., Akseer, N., Subedi, R. K., Brar, S., Bhattarai, B., Dhungana, R. R., Islam, M., Mainali, A., Pradhan, N., Tasic, H., et al. (2020) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqaa218 · Cited by 63 · see citing works
Sanitation for Low-Income Regions: A Cross-Disciplinary Review
Hyun, C., Burt, Z., Crider, Y. S., Nelson, K. L., Prasad, C. S. S., Rayasam, S. D. G., Tarpeh, W. A., & Ray, I. (2019) · Annual Review of Environment and Resources · doi:10.1146/annurev-environ-101718-033327 · Cited by 58 · see citing works
Rakotomanana, H., Komakech, J. J., Walters, C. A., & Stoecker, B. J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17176262 · Cited by 55 · see citing works
Prado, E. L., Arnold, C. D., Wessells, K. R., Stewart, C. P., Abbeddou, S., Adu‐Afarwuah, S., Arnold, B. F., Ashorn, U., Ashorn, P., Becquey, E., et al. (2021) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqab277 · Cited by 55 · see citing works
Self-citationMontealegre, M. C., Roy, S., Böni, F., Hossain, M. I., Navab-Daneshmand, T., Caduff, L., Faruque, A. S. G., Islam, M. A., & Julian, T. R. (2018) · Applied and Environmental Microbiology · doi:10.1128/aem.01978-18 · Cited by 55 · see citing works
Foster, T., Falletta, J., Amin, N., Rahman, M. M., Liu, P., Raj, S., Mills, F., Petterson, S., Norman, G., Moe, C. L., et al. (2021) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2020.113669 · Cited by 54 · see citing works
Wessells, K. R., Arnold, C. D., Stewart, C. P., Prado, E. L., Abbeddou, S., Adu‐Afarwuah, S., Arnold, B. F., Ashorn, P., Ashorn, U., Becquey, E., et al. (2021) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqab276 · Cited by 53 · see citing works
Self-citationKwong, L. H., Ercümen, A., Pickering, A. J., Arsenault, J. E., Islam, M., Parvez, S. M., UNICOMB, L. E., Rahman, M. M., Davis, J., & Luby, S. P. (2020) · Environmental Science & Technology · doi:10.1021/acs.est.0c02606 · Cited by 51 · see citing works
Self-citationApanga, P. A., & Kumbeni, M. T. (2021) · BMC Pediatrics · doi:10.1186/s12887-021-02546-x · Cited by 52 · see citing works
Majorin, F., Torondel, B., Chan, G. K. S., & Clasen, T. (2019) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011055.pub2 · Cited by 52 · see citing works
Self-citationImplications of WASH Benefits trials for water and sanitation
Cumming, O., & Curtis, V. (2018) · The Lancet Global Health · doi:10.1016/s2214-109x(18)30192-x · Cited by 52 · see citing works
Bekele, T., Rawstorne, P., & Rahman, B. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-034812 · Cited by 51 · see citing works
Dewey, K. G., Arnold, C. D., Wessells, K. R., Prado, E. L., Abbeddou, S., Adu‐Afarwuah, S., Ali, H., Arnold, B. F., Ashorn, P., Ashorn, U., et al. (2022) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqac232 · Cited by 51 · see citing works
Self-citationThystrup, C., Majowicz, S. E., Belina, D., Desta, B. N., Fayemi, O. E., Ayolabi, C. I., Hugho, E. A., Buys, E. M., Akanni, G. B., Machava, N. E., et al. (2024) · BMC Public Health · doi:10.1186/s12889-024-19334-8 · Cited by 51 · see citing works
Aragie, S., Wittberg, D. M., Tadesse, W., Dagnew, A., Hailu, D., Chernet, A., Melo, J. S., Aiemjoy, K., Haile, M., Zeru, T., et al. (2021) · The Lancet Global Health · doi:10.1016/s2214-109x(21)00409-5 · Cited by 49 · see citing works
Self-citationBauza, V., Madadi, V. O., Ocharo, R. M., Nguyen, T. H., & Guest, J. S. (2019) · Environmental Science & Technology · doi:10.1021/acs.est.8b06583 · Cited by 49 · see citing works
Gough, E. K., Moulton, L. H., Mutasa, K., Ntozini, R., Stoltzfus, R. J., Majo, F. D., Smith, L. E., Panić, G., Giallourou, N., Jamell, M., et al. (2020) · PLoS neglected tropical diseases · doi:10.1371/journal.pntd.0007963 · Cited by 48 · see citing works
Steinbaum, L., Mboya, J., Mahoney, R., Njenga, S. M., Null, C., & Pickering, A. J. (2019) · PLoS neglected tropical diseases · doi:10.1371/journal.pntd.0007180 · Cited by 45 · see citing works
Self-citationHuybregts, L., Port, A. L., Becquey, E., Zongrone, A. A., Barba, F. M., Rawat, R., Leroy, J. L., & Ruel, M. T. (2019) · PLoS Medicine · doi:10.1371/journal.pmed.1002892 · Cited by 48 · see citing works
Whittington, D., Radin, M., & Jeuland, M. (2019) · Oxford Review of Economic Policy · doi:10.1093/oxrep/grz029 · Cited by 46 · see citing works
Haque, S. S., & Freeman, M. C. (2021) · Environmental Health Perspectives · doi:10.1289/ehp7762 · Cited by 48 · see citing works
Clasen, T., & Smith, K. R. (2019) · Environmental Health Perspectives · doi:10.1289/ehp4752 · Cited by 46 · see citing works
Self-citationThe Lancet Commission on water, sanitation and hygiene, and health
Ambelu, A. B., Ban, R., Bhagwan, J., Brown, J. M., Chilengi, R., Chandler, C., Colford, J. M., Cumming, O., Curtis, V. A., Evans, B., et al. (2021) · The Lancet · doi:10.1016/s0140-6736(21)02005-5 · Cited by 46 · see citing works
Self-citationRandomized Control Trials in the Field of Development
Bédécarrats, F., Guérin, I., & Roubaud, F. (2020) · doi:10.1093/oso/9780198865360.001.0001 · Cited by 48 · see citing works
Morse, T., Tilley, E., Chidziwisano, K., Malolo, R., & Musaya, J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17082648 · Cited by 45 · see citing works
McGuinness, S. L., O’Toole, J., Barker, F., Forbes, A. B., Boving, T. B., Giriyan, A., Patil, K., D’Souza, F., Vhaval, R., Cheng, A. C., et al. (2020) · Environmental Science & Technology · doi:10.1021/acs.est.9b04818 · Cited by 45 · see citing works
Chidziwisano, K., Slekiene, J., Mosler, H., & Morse, T. (2020) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.19-0528 · Cited by 44 · see citing works
Implications of WASH Benefits trials for water and sanitation
Coffey, D., & Spears, D. (2018) · The Lancet Global Health · doi:10.1016/s2214-109x(18)30225-0 · Cited by 44 · see citing works
Hossain, A., Niroula, B., Duwal, S., Ahmed, S., & Kibria, M. G. (2020) · Heliyon · doi:10.1016/j.heliyon.2020.e03849 · Cited by 43 · see citing works
Measuring growth and medium‐ and longer‐term outcomes in malnourished children
Owino, V. O., Murphy‐Alford, A. J., Kerac, M., Bahwere, P., Friis, H., Berkley, J. A., & Jackson, A. A. (2019) · Maternal and Child Nutrition · doi:10.1111/mcn.12790 · Cited by 42 · see citing works
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Rosenthal, J. P., Arku, R. E., Baumgartner, J., Brown, J. M., Clasen, T., Eisenberg, J. N. S., Hovmand, P. S., Jagger, P., Luke, D. A., Quinn, A., et al. (2020) · Environmental Health Perspectives · doi:10.1289/ehp7010 · Cited by 42 · see citing works
Self-citationRational Habit Formation: Experimental Evidence from Handwashing in India
Hussam, R., Rabbani, A., Reggiani, G., & Rigol, N. (2021) · American Economic Journal Applied Economics · doi:10.1257/app.20190568 · Cited by 67 · see citing works
Brander, R. L., Pavlinac, P. B., Walson, J. L., John-Stewart, G. C., Weaver, M. R., Faruque, A. S. G., Zaidi, A. K. M., Sur, D., Sow, S. O., Hossain, M. J., et al. (2019) · BMC Medicine · doi:10.1186/s12916-019-1441-3 · Cited by 41 · see citing works
Workman, C. L., Cairns, M. R., Reyes, F. L. D. L., & Verbyla, M. E. (2021) · Environmental Engineering Science · doi:10.1089/ees.2020.0321 · Cited by 42 · see citing works
- Authors
- Null, C., Stewart, C. P., Pickering, A. J., Dentz, H. N., Arnold, B. F., Arnold, C. D., Benjamin-Chung, J., Clasen, T., Dewey, K. G., Fernald, L. C. H., Hubbard, A. E., Kariger, P., Lin, A., Luby, S. P., Mertens, A., Njenga, S. M., Nyambane, G., Ram, P. K., & Colford, J. M.
- Affiliations
- Innovations for Poverty Action (US)
- University of California, Davis (US)
- Tufts University (US)
- University of California, Berkeley (US)
- Emory University (US)
- Stanford Medicine (US)
- Kenya Medical Research Institute (KE)
- University at Buffalo, State University of New York (US)
- Corresponding author
- Null, Clair
- ORCID
- Venue
- The Lancet Global Health
- Publisher
- Elsevier BV
- Published
- 2018-03
- Volume
- 6
- Issue
- 3
- Pages
- e316-e329
- ISSN
- 2214-109X (ISSN-L)
- PMC
- PMC5809717
- OpenAlex
- W4239240204
- Cited by
- 602
- References
- 26
- Citations by year
- 2026: 42 · 2025: 44 · 2024: 61 · 2023: 50 · 2022: 59 · 2021: 109 · 2020: 110 · 2019: 86 · 2018: 38 · 2017: 1
- FWCI
- 70.90
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- The Lancet Global Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- Bill and Melinda Gates Foundation (AID-OAA-F-13-00040)
- United States Agency for International Development
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Social Sciences › Safety Research › Poverty, Education, and Child Welfare
- Keywords
- diarrhea, child growth faltering, water, sanitation and hygiene interventions, handwashing with soap, chlorinated drinking water, fecal contamination, lipid-based nutrient supplements, length-for-age z-score, home visits, rural Kenya, fecal-oral transmission, diarrhea prevention
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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