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Cited by 602Child Nutrition and Water AccessGlobal Maternal and Child HealthPoverty, Education, and Child Welfare

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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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Null, Clair, Stewart, Christine P, Pickering, Amy J, Dentz, Holly N, Arnold, Benjamin F, Arnold, Charles D, Benjamin-Chung, Jade, Clasen, Thomas, Dewey, Kathryn G, Fernald, Lia C H, Hubbard, Alan E, Kariger, Patricia, Lin, Audrie, Luby, Stephen P, Mertens, Andrew, Njenga, Sammy M, Nyambane, Geoffrey, Ram, Pavani K, Colford, John M·2018·The Lancet Global Health
DOI 10.1016/s2214-109x(18)30005-6PMC PMC5809717
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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.

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Figure 1 Trial profile and analysis populations for primary outcomes LAZ=length-for-age Z scores. *Stillbirth and child death counts are cumulative.
Figure 1 Trial profile and analysis populations for primary outcomes LAZ=length-for-age Z scores. *Stillbirth and child death counts are cumulative.CC BY · PubMed Central
Figure 2 Intervention effects on diarrhoea prevalence 1 and 2 years after intervention Data are mean (95% CI). ref=reference. WSH=water, sanitation, and handwashing.
Figure 2 Intervention effects on diarrhoea prevalence 1 and 2 years after intervention Data are mean (95% CI). ref=reference. WSH=water, sanitation, and handwashing.CC BY · PubMed Central
Figure 3 Intervention effects on length-for-age Z scores in 6583 children after 2 years of intervention Kernel density plots show the distribution of length-for-age Z scores; dashed lines are the comparison group distribution and solid lines are the active comparator distribution. (A) Passive control vs active control. (B) Water vs active control. (C) Sanitation vs active control. (D) Handwashing vs active control. (E) WSH vs active control. (F) Nutrition vs active control. (G) WSH and nutrition vs active control. (H) WSH and nutrition vs nutrition. (I) WSH and nutrition vs WSH. p values for t test are for differences in group means from zero; permutation p values test the null hypothesis of no difference between groups using a Wilcoxon signed-rank test statistic. WSH=water, sanitation, and handwashing.
Figure 3 Intervention effects on length-for-age Z scores in 6583 children after 2 years of intervention Kernel density plots show the distribution of length-for-age Z scores; dashed lines are the comparison group distribution and solid lines are the active comparator distribution. (A) Passive control vs active control. (B) Water vs active control. (C) Sanitation vs active control. (D) Handwashing vs active control. (E) WSH vs active control. (F) Nutrition vs active control. (G) WSH and nutrition vs active control. (H) WSH and nutrition vs nutrition. (I) WSH and nutrition vs WSH. p values for t test are for differences in group means from zero; permutation p values test the null hypothesis of no difference between groups using a Wilcoxon signed-rank test statistic. WSH=water, sanitation, and handwashing.CC BY · PubMed Central

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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)
DOI
10.1016/s2214-109x(18)30005-6
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
FWCI
70.90
Type
journal article
Language
en
Open access
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 › Development › 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

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