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Cited by 501Child Nutrition and Water AccessGlobal Maternal and Child HealthPublic Health and Nutrition

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial

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Humphrey, Jean H, Mbuya, Mduduzi N N, Ntozini, Robert, Moulton, Lawrence H, Stoltzfus, Rebecca J, Tavengwa, Naume V, Mutasa, Kuda, Majo, Florence +619 more·2019·The Lancet Global Health
DOI 10.1016/s2214-109x(18)30374-7PMC PMC6293965
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Abstract

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.

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Humphrey, J. H., Mbuya, M. N. N., Ntozini, R., Moulton, L. H., Stoltzfus, R. J., Tavengwa, N. V., Mutasa, K., Majo, F., Mutasa, B., Mangwadu, G., Chasokela, C. M., Chigumira, A., Chasekwa, B., Smith, L. E., Tielsch, J. M., Jones, A. D., Manges, A. R., Maluccio, J. A., Prendergast, A. J., Humphrey, J. H., Jones, A. D., Manges, A., Mangwadu, G., Maluccio, J. A., Mbuya, M. N. N., Moulton, L. H., Ntozini, R., Prendergast, A. J., Stoltzfus, R. J., Tielsch, J. M., Chasokela, C., Chigumira, A., Heylar, W., Hwena, P., Kembo, G., Majo, F. D., Mutasa, B., Mutasa, K., Rambanepasi, P., Sauramba, V., Tavengwa, N. V., Van Der Keilen, F., Zambezi, C., Chidhanguro, D., Chigodora, D., Chipanga, J. F., Gerema, G., Magara, T., Mandava, M., Mavhudzi, T., Mazhanga, C., Muzaradope, G., Mwapaura, M. T., Phiri, S., Tengende, A., Banda, C., Chasekwa, B., Chidamba, L., Chidawanyika, T., Chikwindi, E., Chingaona, L. K., Chiorera, C. K., Dandadzi, A., Govha, M., Gumbo, H., Gwanzura, K. T., Kasaru, S., Makasi, R., Matsika, A. M., Maunze, D., Mazarura, E., Mpofu, E., Mushonga, J., Mushore, T. E., Muzira, T., Nembaware, N., Nkiwane, S., Nyamwino, P., Rukobo, S. D., Runodamoto, T., Seremwe, S., Simango, P., Tome, J., Tsenesa, B., Amadu, U., Bangira, B., Chiveza, D., Hove, P., Jombe, H. A., Kujenga, D., Madhuyu, L., Makoni, P. M., Maramba, N., Maregere, B., Marumani, E., Masakadze, E., Mazula, P., Munyanyi, C., Musanhu, G., Mushanawani, R. C., Mutsando, S., Nazare, F., Nyarambi, M., Nzuda, W., Sigauke, T., Solomon, M., Tavengwa, T., Biri, F., Chafanza, M., Chaitezvi, C., Chauke, T., Chidzomba, C., Dadirai, T., Fundira, C., Gambiza, A. C., Godzongere, T., Kuona, M., Mafuratidze, T., Mapurisa, I., Mashedze, T., Moyo, N., Musariri, C., Mushambadope, M., Mutsonziwa, T. R., Muzondo, A., Mwareka, R., Nyamupfukudza, J., Saidi, B., Sakuhwehwe, T., Sikalima, G., Tembe, J., Chekera, T. E., Chihombe, O., Chikombingo, M., Chirinda, T., Chivizhe, A., Hove, R., Kufa, R., Machikopa, T. F., Mandaza, W., Mandongwe, L., Manhiyo, F., Manyaga, E., Mapuranga, P., Matimba, F. S., Matonhodze, P., Mhuri, S., Mike, J., Ncube, B., Nderecha, W. T. S., Noah, M., Nyamadzawo, C., Penda, J., Saidi, A., Shonhayi, S., Simon, C., Tichagwa, M., Chamakono, R., Chauke, A., Gatsi, A. F., Hwena, B., Jawi, H., Kaisa, B., Kamutanho, S., Kaswa, T., Kayeruza, P., Lunga, J., Magogo, N., Manyeruke, D., Mazani, P., Mhuriyengwe, F., Mlambo, F., Moyo, S., Mpofu, T., Mugava, M., Mukungwa, Y., Muroyiwa, F., Mushonga, E., Nyekete, S., Rinashe, T., Sibanda, K., Chemhuru, M., Chikunya, J., Chikwavaire, V. F., Chikwiriro, C., Chimusoro, A., Chinyama, J., Gwinji, G., Hoko-Sibanda, N., Kandawasvika, R., Madzimure, T., Maponga, B., Mapuranga, A., Marembo, J., Matsunge, L., Maunga, S., Muchekeza, M., Muti, M., Nyamana, M., Azhuda, E., Bhoroma, U., Biriyadi, A., Chafota, E., Chakwizira, A., Chamhamiwa, A., Champion, T., Chazuza, S., Chikwira, B., Chingozho, C., Chitabwa, A., Dhurumba, A., Furidzirai, A., Gandanga, A., Gukuta, C., Macheche, B., Marihwi, B., Masike, B., Mutangandura, E., Mutodza, B., Mutsindikwa, A., Mwale, A., Ndhlovu, R., Nduna, N., Nyamandi, C., Ruvata, E., Sithole, B., Urayai, R., Vengesa, B., Zorounye, M., Bamule, M., Bande, M., Chahuruva, K., Chidumba, L., Chigove, Z., Chiguri, K., Chikuni, S., Chikwanda, R., Chimbi, T., Chingozho, M., Chinhamo, O., Chinokuramba, R., Chinyoka, C., Chipenzi, X., Chipute, R., Chiribhani, G., Chitsinga, M., Chiwanga, C., Chiza, A., Chombe, F., Denhere, M., Dhamba, E., Dhamba, M., Dube, J., Dzimbanhete, F., Dzingai, G., Fusira, S., Gonese, M., Gota, J., Gumure, K., Gwaidza, P., Gwangwava, M., Gwara, W., Gwauya, M., Gwiba, M., Hamauswa, J., Hlasera, S., Hlukani, E., Hotera, J., Jakwa, L., Jangara, G., Janyure, M., Jari, C., Juru, D., Kapuma, T., Konzai, P., Mabhodha, M., Maburutse, S., Macheka, C., Machigaya, T., Machingauta, F., Machokoto, E., Madhumba, E., Madziise, L., Madziva, C., Madzivire, M., Mafukise, M., Maganga, M., Maganga, S., Mageja, E., Mahanya, M., Mahaso, E., Mahleka, S., Makanhiwa, P., Makarudze, M., Makeche, C., Makopa, N., Makumbe, R., Mandire, M., Mandiyanike, E., Mangena, E., Mangiro, F., Mangwadu, A., Mangwengwe, T., Manhidza, J., Manhovo, F., Manono, I., Mapako, S., Mapfumo, E., Mapfumo, T., Mapuka, J., Masama, D., Masenge, G., Mashasha, M., Mashivire, V., Matunhu, M., Mavhoro, P., Mawuka, G., Mazango, I., Mazhata, N., Mazuva, D., Mazuva, M., Mbinda, F., Mborera, J., Mfiri, U., Mhandu, F., Mhike, C., Mhike, T., Mhuka, A., Midzi, J., Moyo, S., Mpundu, M., Msekiwa, N., Msindo, D., Mtisi, C., Muchemwa, G., Mujere, N., Mukaro, E., Muketiwa, K., Mungoi, S., Munzava, E., Muoki, R., Mupura, H., Murerwa, E., Murisi, C., Muroyiwa, L., Muruvi, M., Musemwa, N., Mushure, C., Mutero, J., Mutero, P., Mutumbu, P., Mutya, C., Muzanango, L., Muzembi, M., Muzungunye, D., Mwazha, V., Ncube, T., Ndava, T., Ndlovu, N., Nehowa, P., Ngara, D., Nguruve, L., Nhigo, P., Nkiwane, S., Nyanyai, L., Nzombe, J., Office, E., Paul, B., Pavari, S., Ranganai, S., Ratisai, S., Rugara, M., Rusere, P., Sakala, J., Sango, P., Shava, S., Shekede, M., Shizha, C., Sibanda, T., Tapambwa, N., Tembo, J., Tinago, N., Tinago, V., Toindepi, T., Tovigepi, J., Tuhwe, M., Tumbo, K., Zaranyika, T., Zaru, T., Zimidzi, K., Zindo, M., Zindonda, M., Zinhumwe, N., Zishiri, L., Ziyambi, E., Zvinowanda, J., Bepete, E., Chiwira, C., Chuma, N., Fari, A., Gavi, S., Gunha, V., Hakunandava, F., Huku, C., Hungwe, G., Maduke, G., Manyewe, E., Mapfumo, T., Marufu, I., Mashiri, C., Mazenge, S., Mbinda, E., Mhuri, A., Muguti, C., Munemo, L., Musindo, L., Ngada, L., Nyembe, D., Taruvinga, R., Tobaiwa, E., Banda, S., Chaipa, J., Chakaza, P., Chandigere, M., Changunduma, A., Chibi, C., Chidyagwai, O., Chidza, E., Chigatse, N., Chikoto, L., Chingware, V., Chinhamo, J., Chinhoro, M., Chiripamberi, A., Chitavati, E., Chitiga, R., Chivanga, N., Chivese, T., Chizema, F., Dera, S., Dhliwayo, A., Dhononga, P., Dimingo, E., Dziyani, M., Fambi, T., Gambagamba, L., Gandiyari, S., Gomo, C., Gore, S., Gundani, J., Gundani, R., Gwarima, L., Gwaringa, C., Gwenya, S., Hamilton, R., Hlabano, A., Hofisi, E., Hofisi, F., Hungwe, S., Hwacha, S., Hwara, A., Jogwe, R., Kanikani, A., Kuchicha, L., Kutsira, M., Kuziyamisa, K., Kuziyamisa, M., Kwangware, B., Lozani, P., Mabuto, J., Mabuto, V., Mabvurwa, L., Machacha, R., Machaya, C., Madembo, R., Madya, S., Madzingira, S., Mafa, L., Mafuta, F., Mafuta, J., Mahara, A., Mahonye, S., Maisva, A., Makara, A., Makover, M., Mambongo, E., Mambure, M., Mandizvidza, E., Mangena, G., Manjengwa, E., Manomano, J., Mapfumo, M., Mapfurire, A., Maphosa, L., Mapundo, J., Mare, D., Marecha, F., Marecha, S., Mashiri, C., Masiya, M., Masuku, T., Masvimbo, P., Matambo, S., Matarise, G., Matinanga, L., Matizanadzo, J., Maunganidze, M., Mawere, B., Mawire, C., Mazvanya, Y., Mbasera, M., Mbono, M., Mhakayakora, C., Mhlanga, N., Mhosva, B., Moyo, N., Moyo, O., Moyo, R., Mpakami, C., Mpedzisi, R., Mpofu, E., Mpofu, E., Mtetwa, M., Muchakachi, J., Mudadada, T., Mudzingwa, K., Mugwira, M., Mukarati, T., Munana, A., Munazo, J., Munyeki, O., Mupfeka, P., Murangandi, G., Muranganwa, M., Murenjekwa, J., Muringo, N., Mushaninga, T., Mutaja, F., Mutanha, D., Mutemeri, P., Mutero, B., Muteya, E., Muvembi, S., Muzenda, T., Mwenjota, A., Ncube, S., Ndabambi, T., Ndava, N., Ndlovu, E., Nene, E., Ngazimbi, E., Ngwalati, A., Nyama, T., Nzembe, A., Pabwaungana, E., Phiri, S., Pukuta, R., Rambanapasi, M., Rera, T., Samanga, V., Shirichena, S., Shoko, C., Shonhe, M., Shuro, C., Sibanda, J., Sibangani, E., Sibangani, N., Sibindi, N., Sitotombe, M., Siwawa, P., Tagwirei, M., Taruvinga, P., Tavagwisa, A., Tete, E., Tete, Y., Thandiwe, E., Tibugari, A., Timothy, S., Tongogara, R., Tshuma, L., Tsikira, M., Tumba, C., Watinaye, R., Zhiradzango, E., Zimunya, E., Zinengwa, L., Ziupfu, M., Ziyambe, J., Church, J. A., Desai, A., Fundira, D., Gough, E., Kambarami, R. A., Matare, C. R., Malaba, T. R., Mupfudze, T., Ngure, F., Smith, L. E., Curtis, V., Dickin, K. L., Habicht, J.-P., Masimirembwa, C., Morgan, P., Pelto, G. H., Sheffner-Rogers, C., Thelingwani, R., Turner, P., Zungu, L., Makadzange, T., Mujuru, H. A., Nyachowe, C., Chakadai, R., Chanyau, G., Makamure, M. G., Chiwariro, H., Mtetwa, T., Chikunya, J., Maguwu, L., Nyadundu, S., Moyo, T., Chayima, B., Mvindi, L., Rwenhamo, P., Muzvarwandoga, S., Chimukangara, R., Njovo, H., & Makoni, T.
Affiliations
  • Zvitambo Institute for Maternal and Child Health Research (ZW)
  • Johns Hopkins University (US)
  • Cornell University (US)
  • Middlebury College (US)
  • George Washington University (US)
Corresponding author
Chiwariro, Humphrey
ORCID
Venue
The Lancet Global Health
Publisher
Elsevier BV
Published
2019-01
Volume
7
Issue
1
Pages
e132-e147
ISSN
2214-109X (ISSN-L)
DOI
10.1016/s2214-109x(18)30374-7
PMC
PMC6293965
OpenAlex
W2903935951
Cited by
501
References
2
Citations by year
2026: 38 · 2025: 35 · 2024: 58 · 2023: 57 · 2022: 60 · 2021: 92 · 2020: 102 · 2019: 54 · 2018: 4
FWCI
52.12
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Global Health (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Greater South Information System
Funders
  • Bill and Melinda Gates Foundation (OPP1021542, OPP1143707)
  • UNICEF (PCA–2017–0002)
  • Johns Hopkins University
  • Wellcome Trust (093768/Z/10/Z, 108065, 093768/Z/10/Z and 108065/Z/15/Z, 108065/Z/15/Z, /Z/15/Z, 108065/Z/15)
  • Department for International Development (093768/Z/10/Z)
  • National Institutes of Health
  • Johns Hopkins Bloomberg School of Public Health (OPP1143707)
  • Direktion für Entwicklung und Zusammenarbeit (8106727)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD060338)
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
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Public Health and Nutrition
Keywords
child stunting, anemia, water, sanitation and hygiene, infant and young child feeding, lipid-based nutrient supplements, hand washing station, ventilated improved pit latrines, length-for-age z-score, hemoglobin levels, rural Zimbabwe, community-based intervention, factorial trial
MeSH terms
Adult, Anemia, Child, Preschool, Female, Growth Disorders, Humans, Hygiene, Infant, Infant Nutritional Physiological Phenomena, Male, Pregnancy, Rural Health, Sanitation, Water Supply, Zimbabwe

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