Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial

In the WASH Benefits cluster-randomised controlled trial, we found no effect of any interventions (improved water quality, safe sanitation, handwashing, nutrition, or combinations of the interventions) on caregiver-reported diarrhoea prevalence during the first 2 years of life, and improvements in growth were only observed in groups including the nutrition intervention (maternal, infant, and young child feeding counselling and LNS distribution). With a large sample size and high-quality anthropometric measurements, this trial was powered to detect small effects in diarrhoea prevalence and length-for-age Z score had they been present. Lower adherence to the water and handwashing interventions by the end of the 2 years of intervention does not seem to be the only explanation for the absence of benefits: there were also no reductions in diarrhoea or improvements in growth in children in the water, handwashing, sanitation, or combined water, sanitation, and handwashing groups even in the first year (a typical measurement point in previous trials), when community-based promoters were most active and adherence was higher, whereas almost all of the growth benefits in the nutrition group and combined water, sanitation, handwashing, and nutrition group were already manifest in the first year. Adherence to the interventions was comparable to or better than what a government or large non-governmental organisation might hope to achieve at scale (appendix p 22), with increases in adherence indicators of 30 percentage points or higher in all intervention groups relative to the control in the first year.

These findings contrast with several systematic reviews13x13Wolf, J, Prüss-Ustün, A, Cumming, O et al. Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Health. 2014;
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,14x14Clasen, TF, Alexander, KT, Sinclair, D et al. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev. 2015;
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that have found significant protective benefits of water, sanitation, and hygiene interventions (including handwashing) on diarrhoea in efficacy trials, although most of these studies were shorter and had higher adherence. Results from other trials16x16Pickering, AJ, Djebbari, H, Lopez, C, Coulibaly, M, and Alzua, ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Health. 2015;
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also showed no effect of improved sanitation on diarrhoea, although differences in contexts and interventions complicate comparisons between these trials. Our trial differed from previous trials in that the intervention shifted households from unimproved sanitation (rather than open defecation) to improved sanitation. Additionally, the prevalence of diarrhoea in this study population was high, consistent with prevalence in 12–23-month-old infants measured in the 2014 Kenya Demographic and Health Survey.19x19Kenya National Bureau of Statistics, Ministry of Health, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development, and ICF International. Kenya Demographic and Health Survey 2014. ICF International,
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A systematic review and meta-analysis20x20Dangour, AD, Watson, L, Cumming, O et al. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database Syst Rev. 2013;
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Conversely, counselling and LNS provided in the nutrition group improved length-for-age Z score by year 2. Compared with randomised controlled trials of LNS during complementary feeding, our finding of length-for-age Z score improvements of 0·13–0·16 in the nutrition groups falls in the middle of the spectrum between four trials: one from Malawi23x23Maleta, KM, Phuka, J, Alho, L et al. Provision of 10–40 g/d lipid-based nutrient supplements from 6 to 18 months of age does not prevent linear growth faltering in Malawi. J Nutr. 2015;
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Although there were more improvements in anthropometric measures in the combined water, sanitation, handwashing, and nutrition group versus active control than in the nutrition versus active control group, the differences were of little clinical or statistical significance. We conclude that combining nutrition with water, sanitation, and handwashing did not provide additional growth benefits beyond nutrition alone. Although the effect of water, sanitation, handwashing, and nutrition on mortality was not significant, the lower mortality in that group is consistent with the statistically significant effect of water, sanitation, handwashing, and nutrition on mortality in the Bangladesh trial.9x9Luby, SP, Rahman, M, Arnold, BF et al. Effects of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised trial. Lancet Glob Health. 2018;
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It is possible that the water, sanitation, and handwashing interventions delivered in this trial did not sufficiently address important transmission routes for enteric pathogens.11x11Christensen, G, Dentz, HN, Pickering, AJ et al. Pilot cluster randomized controlled trials to evaluate adoption of water, sanitation, and hygiene interventions and their combination in rural western Kenya. Am J Trop Med Hyg. 2015;
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Additional outcome measures collected in this trial will help to elucidate potential mechanisms for the observed effects, including indicators of environmental contamination, environmental enteric dysfunction, anaemia, enteric parasite infection, and child development. Molecular measurement of infections in the laboratory with stored stool specimens collected as part of this trial offer an opportunity for unbiased indicators of pathogen burden.

More intensive promotion and higher adherence could have resulted in larger effects than those reported, but our findings are relevant for large-scale programmes that struggle to achieve adherence rates as high as those of efficacy studies. The potential for water, sanitation, hygiene, and nutrition interventions to reduce diarrhoea and improve growth might be highly context-dependent. In our rural setting, water was plentiful but rarely available on premises, susceptible to contamination at the source and in storage, and rarely treated despite introduction of a nearly-universal filter distribution programme;30x30Pickering, AJ, Arnold, BF, Dentz, HN, Colford, JM, and Null, C. Climate and health co-benefits in low-income countries: a case study of carbon-financed water filters in Kenya and a call for independent monitoring. Environ Health Perspect. 2017;
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