Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh

A cluster randomised controlled trial

Bibliographic Data

ID23324633
AuthorsStephen P Luby (0000-0001-5385-899X, Stanford Medicine, corresponding author), Mahbubur Rahman (0000-0003-0520-2683, International Centre for Diarrhoeal Disease Research), Benjamin F Arnold (0000-0001-6105-7295, Berkeley Public Health Division), Leanne Unicomb (0000-0002-7757-5641, International Centre for Diarrhoeal Disease Research), Sania Ashraf (0000-0001-9075-7709, International Centre for Diarrhoeal Disease Research), Peter J Winch (0000-0001-8569-5507, Johns Hopkins University), Christine P Stewart (0000-0003-4575-8571, University of California, Davis), Farzana Begum (0000-0002-8725-2723, International Centre for Diarrhoeal Disease Research), Faruqe Hussain (0000-0003-2700-2949, International Centre for Diarrhoeal Disease Research), Jade Benjamin-Chung, Jade Benjamin‐Chung (0000-0003-3631-3132, Berkeley Public Health Division), Elli Leontsini (0000-0001-7895-8065, Johns Hopkins University), Abu Mohd Naser (0000-0002-1347-4446, International Centre for Diarrhoeal Disease Research), Sarker Masud Parvez (0000-0003-2004-5065, International Centre for Diarrhoeal Disease Research), Anne Hubbard (0000-0002-3769-0127, Berkeley Public Health Division), Alan E Hubbard, Audrie Lin (0000-0002-3877-3469, Berkeley Public Health Division), Fosiul Alam Nizame (International Centre for Diarrhoeal Disease Research), Kaniz Jannat (0000-0002-2993-1955, International Centre for Diarrhoeal Disease Research), Ayse Ercumen (0000-0001-6002-1514, Berkeley Public Health Division), Pavani K Ram (0000-0001-6999-4312, University at Buffalo, State University of New York), Kishor Kumar Das (0000-0002-1137-9058, International Centre for Diarrhoeal Disease Research), Jaynal Abedin (0000-0002-4830-4092, International Centre for Diarrhoeal Disease Research), Thomas F Clasen, T Clasen (0000-0003-4062-5788, Emory University), Kathryn G Dewey (0000-0002-4185-3451, University of California, Davis), Lia C H Fernald (0000-0003-1555-4607, Berkeley Public Health Division), Lia C Fernald, Clair Null (0000-0003-0819-536X, Emory University), Tahmeed Ahmed (0000-0002-4607-7439, International Centre for Diarrhoeal Disease Research), Jr John M Colford (0000-0002-3288-6956, Berkeley Public Health Division), John M Colford
Year2018
Volume6
Issue3
Pagese302-e315
Publication date2018-03-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueThe Lancet Global Health (JOURNAL)
Journal identifiersISSN: 2214-109X • E-ISSN: 2572-116X
PublisherElsevier BV (PUBLISHER)
DOI10.1016/s2214-109x(17)30490-4
PMID29396217
OpenAlexW2785371307
LanguageEN
Citations received130
References cited41

BACKGROUND: Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering. METHODS: The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095. FINDINGS: Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46-0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45-0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53-0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49-0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47-0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70-1·13). Compared with control (mean length-for-age Z score -1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15-0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02-0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth. INTERPRETATION: Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions. FUNDING: Bill & Melinda Gates Foundation.

Cluster (spacecraft) · Cluster randomised controlled trial · Environmental health · Hygiene · Psychological intervention · Rural area · Sanitation · Child Nutrition and Water Access · Global Maternal and Child Health · Iron Metabolism and Disorders · Medicine · Nursing · Pediatrics