TY - JOUR
T1 - Effects of water quality, sanitation, handwashing, and nutritional interventions on child development in rural Kenya (WASH Benefits Kenya)
T2 - a cluster-randomised controlled trial
AU - Stewart, Christine P.
AU - Kariger, Patricia
AU - Fernald, Lia
AU - Pickering, Amy J.
AU - Arnold, Charles D.
AU - Arnold, Benjamin F.
AU - Hubbard, Alan E.
AU - Dentz, Holly N.
AU - Lin, Audrie
AU - Meerkerk, Theodora J.
AU - Milner, Erin
AU - Swarthout, Jenna
AU - Colford, John M.
AU - Null, Clair
N1 - Funding Information:
We offer our sincere gratitude to the many study participants who participated in the trial. We also acknowledge the more than 700 community health promoters, 200 field workers, and dozens of supervisors who delivered the interventions, collected the data, and ensured that all protocols were followed. This research was financially supported by Global Development grant OPPGD759 from the Bill & Melinda Gates Foundation to the University of California, Berkeley, and grant AID-OAA-F-13-00040 from the United States Agency for International Development (USAID) to Innovations for Poverty Action. This manuscript was made possible by the generous support of the American people through the USAID. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government.
Funding Information:
All authors declare the receipt of grants and non-financial support from the Bill & Melinda Gates Foundation during the conduct of this study. We declare no further competing interests.
Publisher Copyright:
© 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
PY - 2018/4
Y1 - 2018/4
N2 - Background: Poor nutrition and infectious diseases can prevent children from reaching their developmental potential. We aimed to assess the effects of improvements in water, sanitation, handwashing, and nutrition on early child development in rural Kenya. Methods: In this cluster-randomised controlled trial, we enrolled pregnant women in their second or third trimester from three counties (Kakamega, Bungoma, and Vihiga) in Kenya's western region, with an average of 12 households per cluster. Groups of nine geographically adjacent clusters were block-randomised, using a random number generator, into the six intervention groups (including monthly visits to promote target behaviours), a passive control group (no visits), or a double-sized active control group (monthly household visits to measure child mid-upper arm circumference). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at year 1, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at year 2. Masking of participants was not possible, but data assessors were masked. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105. Findings: Between Nov 27, 2012, and May 21, 2014, 8246 women residing in 702 clusters were enrolled. No clusters were lost to follow-up, but 2212 households with 2279 children were lost to follow-up by year 2. 5791 (69%) children were measured at year 1 and 6107 (73%) at year 2. At year 1, compared with the active control group, the combined water, sanitation, handwashing, and nutrition group had greater rates of attaining the standing with assistance milestone (hazard ratio 1·23, 95% CI 1·09–1·40) and the walking with assistance milestone (1·32, 1·17–1·50), and the handwashing group had a greater rate of attaining the standing alone milestone (1·15, 1·01–1·31). There were no differences when comparing the other intervention groups with the active control group on any of the motor milestone measures at year 1. At year 2, there were no differences among groups for the communication, gross motor, personal social, or combined EASQ scores. Interpretation: The handwashing and combined water, sanitation, handwashing, and nutrition interventions might have improved child motor development after 1 year, although after 2 years there were no other differences between groups. Future research should examine ways to make community health and nutrition programmes more effective at supporting child development. Funding: Bill & Melinda Gates Foundation.
AB - Background: Poor nutrition and infectious diseases can prevent children from reaching their developmental potential. We aimed to assess the effects of improvements in water, sanitation, handwashing, and nutrition on early child development in rural Kenya. Methods: In this cluster-randomised controlled trial, we enrolled pregnant women in their second or third trimester from three counties (Kakamega, Bungoma, and Vihiga) in Kenya's western region, with an average of 12 households per cluster. Groups of nine geographically adjacent clusters were block-randomised, using a random number generator, into the six intervention groups (including monthly visits to promote target behaviours), a passive control group (no visits), or a double-sized active control group (monthly household visits to measure child mid-upper arm circumference). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at year 1, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at year 2. Masking of participants was not possible, but data assessors were masked. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105. Findings: Between Nov 27, 2012, and May 21, 2014, 8246 women residing in 702 clusters were enrolled. No clusters were lost to follow-up, but 2212 households with 2279 children were lost to follow-up by year 2. 5791 (69%) children were measured at year 1 and 6107 (73%) at year 2. At year 1, compared with the active control group, the combined water, sanitation, handwashing, and nutrition group had greater rates of attaining the standing with assistance milestone (hazard ratio 1·23, 95% CI 1·09–1·40) and the walking with assistance milestone (1·32, 1·17–1·50), and the handwashing group had a greater rate of attaining the standing alone milestone (1·15, 1·01–1·31). There were no differences when comparing the other intervention groups with the active control group on any of the motor milestone measures at year 1. At year 2, there were no differences among groups for the communication, gross motor, personal social, or combined EASQ scores. Interpretation: The handwashing and combined water, sanitation, handwashing, and nutrition interventions might have improved child motor development after 1 year, although after 2 years there were no other differences between groups. Future research should examine ways to make community health and nutrition programmes more effective at supporting child development. Funding: Bill & Melinda Gates Foundation.
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U2 - 10.1016/S2352-4642(18)30025-7
DO - 10.1016/S2352-4642(18)30025-7
M3 - Article
C2 - 29616236
AN - SCOPUS:85043591091
SN - 2352-4642
VL - 2
SP - 269
EP - 280
JO - The Lancet Child and Adolescent Health
JF - The Lancet Child and Adolescent Health
IS - 4
ER -