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Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial in Zimbabwe:
1
Jean Humphrey, ScDProfessor, Johns Hopkins Bloomberg School of Public HealthBaltimore MDDirector, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
2
Design and Methods
2 x 2 factorial design:independent and combined effects
ControlStandard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child Feeding
9
Study population:Women in Chirumanzi and Shurugwi districts who became pregnant
between November 2012 - March 2015
10
400 Village Health Workers (VHWs)employed by
Zimbabwe Ministry of Health and Child Care (MoHCC)
• Conducted prospective pregnancy surveillance
• Referred to SHINE
• 5280 women recruited
• Median (IQR) age at enrolment: 12.5 (9,16) wk gestation
43 Research nurses: Assessed outcomes at:
14, 32 wk gest & 1, 3, 6, 12, 18 moAssessed intervention uptake at 12 mo
400 VHWs Delivered treatment-arm-specific
behavior-change interventions at 15 infant age-specific visits
Interventions Outcome assessment
Interventions
12
All children received the Standard of Care (Control) interventions
• Exclusive breastfeeding intervention
• Promoted uptake:
• ANC
• PMTCT
• Immunization
• Family Planning
13
5 mo. 7 mo.
Module 1Into to IYCF
Keep breast-feeding!
Module 2Thick porridge
Nutributter
Module 3Process food
“A baby can eat anything adults
eat”
The IYCF Intervention
6 mo.
18 mo
Module 4Feeding baby during illness
8 mo.
Nutributter delivered monthly
Module 5Feed your baby from each food
group
9 mo.
20-24 wkgest
The WASH Intervention
29 wk gest 4 mo.2 mo. 5 mo.Birth
5 Core Modules
20-24 wkgest
Module 1Put all feces in
latrine.Latrine
constructed
The WASH Intervention
18 mo
Use latrine
Centralized brick and
slab moulding
Community builders
MoHCCsupervised
2500 WASH latrines at enrolment
2500 Non-Wash latrines
after trial
20-24 wkgest
Module 1Put all feces in
latrine.Latrine
constructedTippy Tapsinstalled
The WASH Intervention
18 mo
Use latrine
Module 2Handwashing with soap at key times
Soap delivered
29 wk gest
Soap delivered monthly
20-24 wkgest
Module 1Put all feces in
latrine.Latrine
constructedTippy Tapsinstalled
The WASH Intervention
18 mo
Use latrine
Module 2Handwashing with soap at key times
Soap delivery
29 wk gest
Soap delivered monthly
Module 3Protect
child from feces and soil
ingestionPlay space and mat delivered
2 mo.Birth
20-24 wkgest
Module 1Put all feces in
latrine.Latrine
constructedTippy Tapsinstalled
The WASH Intervention
18 mo
Use latrine
Module 2Handwashing with soap at key times
Soap delivery
29 wk gest
Soap delivered monthly
Module 3Protect
child from feces and soil
ingestionPlay space and mat delivered
4 mo.
Module 4Treat drinking
water especially for infant after
EBFWater Guard
delivery
2 mo.
WaterGuarddelivered monthly
Birth
20-24 wkgest
Module 1Put all feces in
latrine.Latrine
constructedTippy Tapsinstalled
The WASH Intervention
18 mo
Use latrine
Module 2Handwashing with soap at key times
Soap delivery
29 wk gest
Soap delivered monthly
Module 3Protect
child from feces and soil
ingestionPlay space and mat delivered
4 mo.
Module 4Treat drinking
water especially for infant after
EBFWater Guard
delivery
2 mo.
WaterGuarddelivered monthly
Birth
Module 5Prepare Hygienic complementary
food
5 mo.
Fidelity of Intervention Delivery
22
% WASH Households receiving commodities
0 20 40 60 80 100
≥ 80% chlorine
≥ 80% soap
Play yard
Baby mat
2 Tippy Taps
VIP latrine
WASH+IYCF WASH
% IYCF household receiving commodities
0 20 40 60 80 100
≥ 80% Nutributter
WASH+IYCF IYCF
25
0
20
40
60
80
100
Baseline 12 months
Open Defecation
SOC IYCF WASH WASH+IYCF
0
20
40
60
80
100
Baseline 12 months
Improved Latrine
SOC IYCF WASH WASH+IYCF
Presence of improved latrine and Open Defecation by Household members at baseline and 12 months
26
0
20
40
60
80
100
Baseline 12 months
Handwashing station with soap and water
SOC IYCF WASH WASH+IYCF
0
20
40
60
80
100
Baseline 12 months
Detectable Chlorine in Drinking Water
SOC IYCF WASH WASH+IYCF
Presence of handwashing station with soap and water AND having detectable chlorine in drinking water at baseline and 12 months
WASH uptake: Infant faeces disposal and geophagia
0
20
40
60
80
100
12 months 12 months 12 months
SOC IYCF WASH WASH+IYCF
Disposes nappy water in latrine
Child ever observed to eat chicken feces
Child ever observed to eat soil
IYCF uptake: Consumed Nutributter past 24 hours
9590
0
20
40
60
80
100SOCIYCFWASHWASH+IYCF
% Children
SHINE outcomes
29
30
5280 pregnant women enrolled
138 (2.6%) Mothers lost363 (6.9%) fetal deaths, 4 mothers died+81 (1.5%) fetuses from twin/triplets840 HIV+ or unknown mothers
3989 live-born HIV unexposed infants191 (4.8%) infant deaths100 (2.5%) lost
3686 infants assessed at 18 months (97% live births surviving to 18 months)
No treatment group interaction
• WASH + IYCF did not have a greater effect on any outcome I will show you today than WASH alone or IYCF alone.
• Presenting collapsed arms – WASH vs non-WASH
• IYCF vs non-IYCF
31
2 x 2 factorial design:independent and combined effects
SOC/Control
Standard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child Feeding
IYCF arms
SOC/Control
Standard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child Feeding
IYCF arms
SOCStandard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child FeedingNon-IYCF IYCF
WASH arms
SOC/Control
Standard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child Feeding
WASH arms
SOCStandard of Care
WASHWater andSanitationHygiene
WASH+
IYCF
IYCFInfant and Young
Child Feeding
Non-WASH
WASH
Impact of Infant and Young Child Feeding (IYCF) Intervention
37
Effect of IYCF on LAZ at 18 months of age
38
Difference due to IYCF
NMean(SD)
Unadjusted(95%CI)
Adjusted(95%CI)
No IYCF
1792 -1.59 (1.08) +0.16 (0.08, 0.23)
p<0.001
+0.13(0.06, 0.20)
p<0.001IYCF 1879 -1.44 (1.06)
Effect of IYCF on Hemoglobin (g/dL) at 18 mth of age
39
Difference due to IYCF
NMean(SD)
Unadjusted(95%CI)
Adjusted(95%CI)
No IYCF
1759 11.63 (1.18) +0.20 (0.13, 0.28)
p<0.001
+0.19(0.12, 0.27)
P<0.001IYCF 1845 11.83 (1.15)
Effect of IYCF on Stunting and Anemia
40
34.6
13.9
27.4
10.5
0
5
10
15
20
25
30
35
40
% Stunted % Anemic
No IYCF IYCF
RR (95%CI)
Unadjusted0.79
(0.72, 0.87)
Adjusted0.81
(0.74, 0.88)
RR (95%CI)
Unadjusted0.75
(0.62, 0.90)
Adjusted0.76
(0.63, 0.92)
Impact of WASH intervention
41
Effect of WASH on LAZ at 18 months of age
Difference due to WASH
NMean(SD)
Unadjusted(95%CI)
Adjusted(95%CI)
No WASH 1769-1.52 (1.07) +0.02
(-0.06, 0.09)p=0.70
+0.05(-0.02, 0.12)
p=0.13WASH 1902-1.50 (1.07)
42
Difference due to WASH
NMean(SD)
Unadjusted(95%CI)
Adjusted(95%CI)
No WASH 174811.75 (1.13) -0.03
(-0.10, 0.05) p=0.47
-0.06(-0.14, 0.02)
p=0.13WASH 185611.72 (1.21)
43
Effect of WASH on Hemoglobin (g/dL) at 18 months of age
Effect of WASH on Stunting and Anemia
44
30.6
11.3
31.2
12.9
0
5
10
15
20
25
30
35
% Stunted % Anemic
No WASH WASH
RR (95%CI)
Unadjusted1.03
(0.93, 1.13)
Adjusted1.00
(0.91, 1.10)
RR (95%CI)
Unadjusted1.14
(0.95, 1.36)
Adjusted1.13
(0.92, 1.37)
Diarrhea
45
46
Main Effects
Prevalence(%)
Difference(95%CI)
pAdjusted(95%CI)
p
NO IYCF
9.9 1.0 (Ref) 1.0 (Ref)
IYCF 9.40.94
(0.77,1.16)0.82
0.97(0.80, 1.20)
0.82
NO WASH
8.4 Ref Ref
WASH 10.71.28
(1.04,1.57)0.02
1.15 (0.93, 1.41)
0.19
7 day diarrhea prevalence at 18 months
Impact of WASH on transmission of 40 enteropathogens at 12 and 18 months using TAC
Mean (SD) score
at 6 months
Mean (SD) score
at 12 months
Difference* in number
of pathogens at 6 &
12 months (95% CI)
Pathogen scores† WASH
Total pathogens 2.6 (1.51) 3.1 (1.46) -0.04 ( -0.21, 0.10)
Bacteria 2.1 (1.25) 2.1 (1.13) 0.05 ( -0.07, 0.16)
Viruses 0.3 (0.53) 0.3 (0.52) 0.00 ( -0.05, 0.05)
Parasites 0.3 (0.54) 0.7 (0.74) -0.09 ( -0.16, -0.03)
47
One new result
48
Rotavirus was the leading cause of diarrhea deaths among young children in GEMS study.
215,000 deaths per year globally
Oral vaccines are less efficacious in developing countries
98.0% RV efficacy in developed countries
39.3% RV efficacy in sub-Saharan Africa
Why the gap in vaccine efficacy?
*Environmental enteric dysfunction*Diarrhea*Subclinical gastrointestinal carriage of pathogens*Altered gut microbiota
These may all respond to WASHRotavirus vaccine introduced in Zimbabwe during SHINE
We investigated the impact of the SHINE WASH intervention on rotavirus vaccine efficacy
Birth
RVV dose 1
Rotavirus Vaccine performance in SHINE
6 weeks 10 weeks
RVV dose 2
Pre-vaccination RV IgA titre
Post-vaccination RV
IgA titre
SHINE 4 week visit
SHINE 12 week visit
Rotavirus vaccine (Rotarix) introduced in May 2014
Primary outcome: WASH increase RVV efficacy from 20% to 30%
Rotavirus seroconversion
Analysis Group n/N %
Absolute difference
(%) (95% CI)
p
Unadjusted AdjustedRelative
Risk (95% CI)
pRelative Risk
(95% CI)p
At least 1 dose vaccine
Non-WASH
43/219
19.610.6
(0.5, 20.7)0.03
1.00(ref)
1.00 (ref)
WASH33/109
30.31.48
(0.98, 2.24)0.06
41.65
(1.12, 2.42)0.01
2 doses vaccine
Non-WASH
41/190
21.613.7
(2.0, 25.4)0.02
1.0 (ref)
1.0 (ref)
WASH30/85
35.31.56
(1.04, 2.34)0.03
31.71
(1.20, 2.45)0.00
The WASH Benefits (Bangladesh and Kenya)and SHINE Trials:
Interpretation of findings on linear growth and diarrhoea
54
55
Environmental and personal hygiene are centrally importantto child growth and other measures of child health
56
Environmental and personal hygiene are centrally importantto child growth and other measures of child health
Current WASH interventions are not effective enough
57
We need to set WASH programming on a trajectory from business as usual toward Transformative WASH:
*Novel approaches to intensive behavior change communication*Innovative technology and tools
*Strengthened governance of systems that deliver these BCC and tools
WASH Benefits trials and SHINE:
58
• WASH interventions typical of rural large-scale WASH programs:• Pit latrine• Handwashing station• POU drinking water chlorination
• Promoted removal of animal and human faeces from the yard: • WASH Benefits trials: “Sani-Scoops“ and potties • SHINE: Clean play space
Together, the three trials:
59
• Studied >18,000 children
• Free latrines, soap, chlorine, Nutributter
• Delivered behaviour change modules based on years of
formative research and pilot testing and grounded in behaviour
change theory
• Implemented WASH to household; Infant Feeding to index child
• Measured outcomes by standardized and supervised research
staff
The three trials: LAZ and Diarrhoea outcomes
60
• In all three trials:
• Infant feeding intervention significantly, but modestly increased linear growth by 0.13 – 0.25 LAZ
• WASH intervention had no effect on LAZ and integrating WASH with IYCF had no additional benefit on linear growth than implementation of IYCF alone
• Diarrhoea outcome:
• In Bangladesh all 6 intervention arms (except water treatment alone)
significantly reduced diarrhoea by 31-40%
• In Kenya and Zimbabwe none of the interventions reduced diarrhoea
4 questions:
61
1. Why did the WASH intervention fail to improve linear growth in all three trials?
2. Why did WASH reduce diarrhoea in Bangladesh but have no impact on diarrhoea in Kenya and Zimbabwe?
3. Would a CATS (Community Approaches to Total Sanitation) been more effective on stunting than the household level interventions implemented?
4. What recommendations can we offer based on all available evidence?
#1: Why did WASH fail to improve linear growth?
62
Throughout history, sweeping improvements in WASH through engineered WASH associated with improved growth
Brazil, Stunting declined 37% to 7% over 30 yearsEngineered WASH was strong statistically attributable factor
#1: Why did WASH fail to improve linear growth?
63
A very high level of hygiene may be required to support normal child growth;
We have evidence from the 3 trials of substantial faecal-oral transmission among children in the WASH arms despite our interventions
Dadirai Fundira, Jean Humphrey, Mduduzi N.N. Mbuya, Gretel Pelto, Larry Moulton, Naume V. Tavengwa, Rebecca J. Stoltzfus
Structured observations at 18 months of age:89 WASH, 90 Non-WASH
WASH mother’s were making visibly dirty objects less available to their children
65
Frequency of mouthing in 6 hours
All objects Visibly dirty objects
Non-WASH 229 102
WASH 228 85
66
Soil ingestion during 6 hour observation
WASH Non-WASH
% infants ingesting soil ≥ once 52% 70%
Frequency of ingesting, among those who ingested soil ≥ once
4.7 (4) 5.0 (4.4)
Mean soil ingestion (g) 9.8 g 10.5 g
Mean E coli ingestion (CFU) 952 1052
WASH Benefits Trials
• Kenya – 40% of mothers reported that their child ate soil in the previous week
• Bangladesh – testing of soil showed very high concentrations of faecal contamination; observations studies showed frequent hand and object mouthing
67
Interpretation
• Despite high uptake of WASH interventions, fecal exposure remained high
68
A very low exposure to fecal contamination may be required to support normal linear growth which can be achieved through engineered WASH interventions but was not achieved in our trials.
If this is true, why have so many observational studies showed strong associations between indicators of rural WASH (not engineered WASH) and growth?
Systematic review of publications from past 3 years:
89 observational studies investigated association of WASH with stunting
49 (55%) showed a significant association between a WASH indicator and growth
Most common: “access to improved sanitation”
We investigated this in the control groups of our trials
69
Country Change in LAZ 95% CI P value
Bangladesh + 0.22 (0.03 – 0.40) 0.02
Kenya + 0.15 (0.02 – 0.28) 0.02
Zimbabwe + 0.20 (0.08 – 0.31) < 0.001
70
Change in LAZ at 18-24 months associated with having improved sanitation at baseline (pregnancy)
In all 3 trials, households in the control arm that had access to improved sanitation during pregnancy had an infant who was 0.2 LAZ longer at 18 - 24 monthsYet, building improved latrines in these communities did not improve linear growth
Suggests:
•Observational estimates of WASH intervention impact may be particularly vulnerable to confounding;
•Use caution in interpreting as evidence for WASH policy and programming
• Triangulate with experimental findings
71
• WASH is essential for normal child growth.
• However, even when implemented rigorously, the elementary interventions delivered in our trials and commonly through rural WASH programmes, have too little impact on reducing faecal-oral transmission compared to the pervasive faecal contamination of living environments of the world’s poorest people.
72
#2 : Why did WASH reduce diarrhoea in Bangladesh but not Kenya or Zimbabwe?
73
Frequency of contact per month between behaviour change promoter and study participant
Kenya 1
Zimbabwe 1
Bangladesh 6
What studies are these statements based on?
“Handwashing with soap before meals and after toilet use has been shown to reduce diarrhoeal infections by 50%”
“Home-based chlorination of drinking water reduces diarrhoea by 25%”
74
#2 : Why did WASH reduce diarrhoea in Bangladesh but not Kenya or Zimbabwe?
75
#2 : Why did WASH reduce diarrhea in Bangladesh but not Kenya or Zimbabwe?
We conducted systematic reviews to examine the
characteristics of the studies that form the evidence bases that:
• Hand-washing promotion reduces diarrhea (19 studies)
• POU water treatment reduces diarrhea (30 studies)
Paid close attention to how often promoters contacted
households
76
Studies of hand-washing and diarrhea: frequency of contact between behavior change promoter and study participant
77
78
Follow up of behaviors after the trials ended
Pakistan hand-washing trial (53% reduction) • Returned 18 months later. • Followed same households for 14 months. • Soap purchasing not different between groups. • Child diarrhea not different between groups.
Guatemala flocculant disinfectant water treatment trial • Just after trial ended, social marketing of the solution rolled out in study
areas. • Six months later: 5% of intervention arm households had purchased
solution in past 2 weeks and used it in past 1 week.
79
• All the evidence that POU water treatment and hand-washing promotion reduce diarrhea comes from studies with very high intervention intensity (mostly daily to weekly contact between promoter and participant).
• Moreover, once these intense interventions stopped, the behaviors stopped, and the benefit on child diarrhea disappeared.
It is unlikely that POU Water treatment and hand-washing promotion implemented programmatically through social marketing, posters or pamphlets, or messages intermittently delivered by community health workers, unaccompanied by further investments in behavior change are reducing child diarrhea
Taken together:
80
#3 Would a CATS have been more effective?Children <2 spend most of their time in their household compound.Households are usually single-family dwellings surrounded by farm land. Mean distance between households was 82.6 m and population density was 18.6 people/Km2.
Perhaps visiting neighbors bring in contamination on their feet which further contaminates the soil children ingest. We think this is modest compared to the animals cohabitating in the household.
We did not chose CATS because introduces high variability in time to latrine and quality of latrine and current CATS programs seldom achieve universal uptake (10-50% OD continuing).
Effects from recent community sanitation studiesStudy Location Coverage Δ(%) Use (%) Exposure Diarrhoea Stunting
Arnold 2010 Tamil Nadu 1548 39
Patil 2014 Madhya Pradesh
2241 27
Clasen 2014 Orissa 863 46
Pickering 2015 Mali 3565 70 Note 1 +0.16 SD
WASH B-B B’desh 3595 (low OD)
>80 Note 2 Note 3
WASH B-K Kenya 1887(low OD)
>80
Gram Vikas Orissa, India 1885 59 +0.17 SD
SHINE (preliminary) Zimbabwe High (?OD)
High ?
1. Fewer observed flies and feces; no change in fecal contamination of water2. Fewer observed soiled hands and less fecal contamination of water 3. Except water quality arm
81
82
#3 Would a CATS have been more effective?
One important exception was a CLTS trial conducted in Mali. The CLTS intervention has no effect on diarrhoea but increased LAZ by 0.18.
Reason 3 – Intervention duration/coverage
• Enrolled women in pregnancy• Aimed for families to change WASH behaviors before the baby
was born• Maybe it takes much longer to clean up heavily contaminated
environments and improve child health outcomes
• All 3 trials tested household-level interventions• Community latrine coverage may be an important factor• Improved LAZ seen in studies from India and Mali
Reese H, #170 ASTMH 2017; Pickering AJ, Lancet Glob Health 2015
84
Conclusions and recommendations for WASH policy and programming
85
Recommendations (1)
The WASH Benefits and SHINE trials provide high quality evidence that implementing the WASH interventions typically implemented in rural areas of LMICs is unlikely to increase child linear growth.
Implementing these interventions together with an infant feeding intervention is unlikely to increase child linear growth more than implementing the infant feeding intervention alone.
Policy and Programming should not promote these elementary WASH interventions alone or integrated with infant feeding interventions for the purpose of reducing stunting
86
Recommendations (2a)
• Virtually all the evidence that POU water treatment and handwashing promotion reduce diarrhoea comes from studies that had daily to fortnightly contact between promoters and households.
• When programme ended, behaviours steeply declined, and the effect on child diarrhoea disappeared.
• The dependence of these interventions on sustained daily to fortnightly behaviour change promotion may not be widely recognized by implementers.
87
Recommendations (2b)
• POU water treatment and hand-washing promotion through intermittent message delivery are unlikely to reduce child diarrhoea without further investment in behavior change, at least among children <2 years, who have the highest diarrhoea prevalence.
88
SHINE findings suggest that even small improvements in gut health might impact seroconversion to oral vaccines which are absorbed in the small intestine.
30% seroconversion is abysmal, but this improvement suggests that more transformative WASH may lead to greater gains.
Rotavirus Vaccine Efficacy
89
Set a trajectory toward “Transformative WASH”
1. Behavior change: More frequent/intense• Use of smart phone technology?
2. More effective technology which relies on less behavior change and reduces barriers to hygiene
3. Stronger governance, management, efficiency of human systems that deliver BCC and technology
90
Water Abundance Xprize awarded October 22, 2018: Skywater
*Harvests 2000 liters clean water from the atmosphere*Sustainable energy*<2 cents per liter
*One more tool to put on the buffet of possibilities for governments to choose from?*Sparsely populated areas where piping is infeasible?*Arid climates without ground water?*Push technology development faster?
91
Possible transformative WASH examples• BCC delivered through approaches that ensure frequent
message delivery or mass media that challenge social norms (parliament members washing hands)
• Complete separation of animal feces from children’s living environments
• Community coverage of sustained high quality sanitation• Continuous plentiful supply of an uncontaminated water
delivered into households (Skywater won Water Abundance Xprize on Oct 22 – 2000 liters/water/day from atmosphere using only renewable energy at a cost of <2 cents/liter
Donors
92
• Bill and Melinda Gates Foundation• Department for International
Development, UK (DFID)• Wellcome Trust
With additional support from:National Institutes of Health, USASwiss Agency for Development and CooperationEuropean Union, UNICEF
Collaborating Institutions and Investigators
93
Zimbabwe Ministry of Health and Child CareGoldberg Mangwadu, Ancikaria Chigumira, Cynthia Chasokela
Zvitambo Institute for Maternal and Child Health ResearchMduduzi Mbuya (currently GAIN), Robert Ntozini, Naume Tavengwa, Kuda Mutasa, Florence Majo, Bernard Chasekwa, Virginia Sauramba, Phillipa Rambanepasi
Johns Hopkins Bloomberg School of Public Health Jean Humphrey, Lawrence Moulton, Margaret Kosek
Queen Mary University of London Andrew Prendergast
Cornell University Rebecca Stoltzfus
University of Liverpool Melissa Gladstone
University of British Columbia Amee Manges
George Washington University James Tielsch
Middlebury College John Maluccio
University of Michigan Andrew Jones
The WASH Benefits trials in Kenya and Bangladesh:
Cluster-randomized controlled trials of water, sanitation, handwashing,
and nutritional interventions in rural settings
Presented by: Clair Null, Ph.D.Mathematica Policy Research and Innovations for Poverty Action
• Cluster-randomized
• Measure effects during the first two years of life
• Enroll pregnant women, follow children 12 & 24 months later
• 7 study arms
1. Double-sized control
2-5. Single interventions (W, S, H, N)
6-7. Combined interventions (WSH, WSHN)
One design, two trials
(Bangladesh: passive; Kenya: active)
Context
Bangladesh Kenya
Population
densityModerate Low
Water sourceShallow tubewell
(in compound)
Protected springs
(10 minute walk)
Sanitation
<60% own a latrine
Of which:
>90% concrete slab but
<33% functional water seal
>80% own a latrine
<20% access improved
Handwashing <10% have soap available at handwashing location
Food security ~30% food insecurity
~10% moderate to severe
household hunger
Target behaviors
Water Treat drinking water with chlorine.
Sanitation Use latrines for defecation and safely dispose of feces.
Handwashing Wash hands with soap before handling food and after defecation.
NutritionPractice UNICEF and Government of Kenya/Bangladesh
guidelines for maternal, infant, and young child feeding.
• Dietary diversity during pregnancy and lactation
• Early initiation of breastfeeding
• Exclusive breastfeeding until 6 months
• Introduction of appropriate and diverse complementary foods
at 6 months
• Continued breastfeeding through 24 months
• Nominated by study participants
• Trained and supported by study staff
• Ratio of 1:8 participants in Bangladesh; 1:~11 in Kenya
• Visits to educate, encourage behaviors, support hardware
• Kenya: monthly during year 1, ~6 weeks during year 2
• Bangladesh: 6 times / month throughout
Community promoters
Mean visits per
month
Handwashing
Nutrition
Water
Sanitation
All Arms
Promoters:
flip charts
summary sheets
Participants:
calendars,
cue cards,
tracking booklets
Enrollment and loss to follow-up
Bangladesh Kenya
Baseline720 clusters,
5551 women
702 clusters,
8246 women
Follow up
(Year 2)
4639
(93% of living children)
6583 children
(86% of living children)
Adherence
% o
f in
dex
ch
ild
ren
ut
7-day diarrhea prevalence
% o
f ch
ild
ren
>3
6m
at
en
roll
men
t
Bangladesh
Kenya
-1.67
-1.53
-1.76
-1.85
-1.80
-1.86
-1.79
-2.00 -1.50 -1.00 -0.50 0.00
Nutrition + W+S+H
Nutrition
W+S+H
Handwashing
Sanitation
Water
Control
p<0.001
p=0.029
Growth - Bangladesh
-1.39
-1.44
-1.59
-1.60
-1.61
-1.58
-1.56
-1.54
-2 -1.5 -1 -0.5 0
Combined WSH+N
Nutrition
Combined WSH
Handwashing
Sanitation
Water
Passive Control
Active Control
Mean length for age Z score
(standard deviations)
2 year follow-up
Growth - Kenya
p=0.032
p=0.004
vs. control:
Anemia
Bangladesh Kenya
Child development
• Extended Ages and Stages Questionnaire
• Bangladesh: Effects on gross motor from N, WSH, WSHN;
effects on personal social from all intervention arms
• Kenya: No effects of any intervention on gross motor,
personal social, or communication
Bangladesh only:
• MacArthur Bates Communicative Development Inventory
• Effects from all arms on understanding and saying
• Almost no effects on tests of executive function
2.9%
3.8%
4.7%
4.5%
4.1%
4.1%
4.7%
0% 1% 2% 3% 4% 5%
Nutrition + W+S+H
Nutrition
W+S+H
Handwashing
Sanitation
Water
Control
Risk Ratio: 0.81; p=0.362
Risk Ratio: 0.62; p=0.037
n=62
n=27
n=29
n=31
n=25
n=19
n=27
Mortality - Bangladesh
2.8
3.8
4.9
5.3
3.9
3.4
4.5
3.8
0 1 2 3 4 5 6
Combined WSH+N
Nutrition
Combined WSH
Handwashing
Sanitation
Water
Passive Control
Active Control
Percent of live births
Mortality - Kenya
Summary
Find links to all WASH Benefits publications at
http://www.washbenefits.net/publications.html
Summary• Same design and similar interventions, different contexts
• Much more promotion in Bangladesh (weekly versus ~6 weeks)
• Higher adherence in Bangladesh, but same growth results in
both countries (N and WSHN only)
• Very different diarrhea results• Bangladesh (very low prevalence - 6%): Impacts on diarrhea from all
interventions except W; direct evidence of reduction in Giardia
• Kenya (very high prevalence - >25%): No impacts on diarrhea or Giardia
• Significant reductions in anemia in both countries; suggestive
indications of WASH effects
• Strong effects on child development from all interventions in
Bangladesh, none in Kenya
• Statistically significant reduction in mortality in WSHN arm in
Bangladesh, similar trend in Kenya
Bangladesh AcknowledgementsICDDR,BAWESOME field teamLeanne UnicombMahbubur RahmanSania AshrafFaruqe HussainFosiul NizameShaila ArmanFarzana BegumAbu NaserSarker Masud ParvezFahmida TofailKishor DasSolaiman DozaRashidul HaqueTahmeed AhmedRubhana RaqibMahfuza Sheuli
In memoriamMothaher Hossain
StanfordAmy PickeringJessica GrembiLaura Kwong
UC DavisChristine StewartKay Dewey
Johns HopkinsPeter WinchElli Leontsini
UC BerkeleyJack ColfordBen ArnoldJade Benjamin-ChungLia FernaldAudrie LinAyse ErcumenPatricia Kariger
University at BuffaloPavani Ram
Emory UniversityTom Clasen
Kenya AcknowledgementsIPA
Geoffrey Nyambane
Theodora Meerkerk
Ryan Mahoney
Liz Jordan
Betty Akoth
Marion Kiprotich
Priscah Cheruiyot
Mathilda Regan
Jenna Swarthout
Stephen Kalungu
Frank Odhiambo
Ronald Omondi
Maryanne Mureithi
Beryl Achando
John Mboya
and the 200+ members of the intervention delivery, data collection, and laboratory teams
UC Berkeley
Jack Colford
Ben Arnold
Audrie Lin
Jade Benjamin-Chung
Andrew Mertens
Lia Fernald
Patricia Kariger
Alan Hubbard
Erin Milner
UC Davis
Christine Stewart
Holly Dentz
Kay Dewey
Charles Arnold
Kendra Byrd
Anne Williams
Stanford University
Steve Luby
Lauren Steinbaum
Tufts University
Amy Pickering
KEMRI
Sammy Njenga
Bernard Chieng
University at Buffalo
Pavani Ram
Emory University
Tom Clasen
Harvard University
Michael Kremerstudy promoters and participants
and the County Health Management Teams for their support
Funding: This research was financially supported by Grant OPPGD759 from the Bill & Melinda Gates
Foundation to the University of California, Berkeley and the generosity of the American people through the
United States Agency for International Development (USAID). The contents of this presentation are the
responsibility of the authors and do not necessarily reflect the views of USAID or the United States
Government.
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