Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh)

a cluster-randomised controlled trial

Fahmida Tofail, Lia CH Fernald, Kishor K. Das, Mahbubur Rahman, Tahmeed Ahmed, Kaniz K. Jannat, Leanne Unicomb, Benjamin F. Arnold, Sania Ashraf, Peter John Winch, Patricia Kariger, Christine P. Stewart, John M. Colford, Stephen P. Luby

Research output: Contribution to journalArticle

Abstract

Background: Poor nutrition and hygiene make children vulnerable to delays in growth and development. We aimed to assess the effects of water quality, sanitation, handwashing, and nutritional interventions individually or in combination on the cognitive, motor, and language development of children in rural Bangladesh. Methods: In this cluster-randomised controlled trial, we enrolled pregnant women in their first or second trimester from rural villages of Gazipur, Kishoreganj, Mymensingh, and Tangail districts of central Bangladesh, with an average of eight women per cluster. Groups of eight geographically adjacent clusters were block-randomised, using a random number generator, into six intervention groups (all of which received weekly visits from a community health promoter for the first 6 months and every 2 weeks for the next 18 months) and a double-sized control group (no intervention or health promoter visit). 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 age 1 year, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at age 2 years. Masking of participants was not possible. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01590095. Findings: Between May 31, 2012, and July 7, 2013, 5551 pregnant women residing in 720 clusters were enrolled. Index children of 928 (17%) enrolled women were lost to follow-up in year 1 and an additional 201 (3%) in year 2. 4757 children were assessed at 1 year and 4403 at 2 years. At year 1, compared with the control group, the combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the standing alone milestone (hazard ratio 1·19, 95% CI 1·01–1 ·40), and the nutrition group had a higher rate of attaining the walking alone milestone (1·32, 95% CI 1·07–1·62). The combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the walking alone milestone than those in the water, sanitation, and handwashing group (1·29, 1·01–1·65). At 2 years, we noted beneficial effects in the combined EASQ score in all intervention groups, with effect sizes smallest in the water treatment group (difference 0·15, 95% CI 0·04 to 0·26 vs control) and largest in the combined water, sanitation, handwashing, and nutrition treatment group (0·37, 0·27–0·46). Interpretation: Improvements in water quality, handwashing, sanitation, or nutrition supported by intensive interpersonal communication, when delivered either individually or in combination, contributed to improvements in child development. A crucial next step is to establish whether similar effects can be achieved with reduced intensity of promoter contacts that could be supported in large-scale interventions. Funding: Bill & Melinda Gates Foundation.

Original languageEnglish (US)
Pages (from-to)255-268
Number of pages14
JournalThe Lancet Child and Adolescent Health
Volume2
Issue number4
DOIs
StatePublished - Apr 1 2018

Fingerprint

Hand Disinfection
Sanitation
Bangladesh
Water Quality
Child Development
Randomized Controlled Trials
Water
Walking
Pregnant Women
Communication
Soaps
Control Groups
Language Development
Intention to Treat Analysis
Water Purification
Lost to Follow-Up
Health
Second Pregnancy Trimester
First Pregnancy Trimester
Hygiene

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Developmental and Educational Psychology

Cite this

Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh) : a cluster-randomised controlled trial. / Tofail, Fahmida; Fernald, Lia CH; Das, Kishor K.; Rahman, Mahbubur; Ahmed, Tahmeed; Jannat, Kaniz K.; Unicomb, Leanne; Arnold, Benjamin F.; Ashraf, Sania; Winch, Peter John; Kariger, Patricia; Stewart, Christine P.; Colford, John M.; Luby, Stephen P.

In: The Lancet Child and Adolescent Health, Vol. 2, No. 4, 01.04.2018, p. 255-268.

Research output: Contribution to journalArticle

Tofail, F, Fernald, LCH, Das, KK, Rahman, M, Ahmed, T, Jannat, KK, Unicomb, L, Arnold, BF, Ashraf, S, Winch, PJ, Kariger, P, Stewart, CP, Colford, JM & Luby, SP 2018, 'Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trial', The Lancet Child and Adolescent Health, vol. 2, no. 4, pp. 255-268. https://doi.org/10.1016/S2352-4642(18)30031-2
Tofail, Fahmida ; Fernald, Lia CH ; Das, Kishor K. ; Rahman, Mahbubur ; Ahmed, Tahmeed ; Jannat, Kaniz K. ; Unicomb, Leanne ; Arnold, Benjamin F. ; Ashraf, Sania ; Winch, Peter John ; Kariger, Patricia ; Stewart, Christine P. ; Colford, John M. ; Luby, Stephen P. / Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh) : a cluster-randomised controlled trial. In: The Lancet Child and Adolescent Health. 2018 ; Vol. 2, No. 4. pp. 255-268.
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T1 - Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh)

T2 - a cluster-randomised controlled trial

AU - Tofail, Fahmida

AU - Fernald, Lia CH

AU - Das, Kishor K.

AU - Rahman, Mahbubur

AU - Ahmed, Tahmeed

AU - Jannat, Kaniz K.

AU - Unicomb, Leanne

AU - Arnold, Benjamin F.

AU - Ashraf, Sania

AU - Winch, Peter John

AU - Kariger, Patricia

AU - Stewart, Christine P.

AU - Colford, John M.

AU - Luby, Stephen P.

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N2 - Background: Poor nutrition and hygiene make children vulnerable to delays in growth and development. We aimed to assess the effects of water quality, sanitation, handwashing, and nutritional interventions individually or in combination on the cognitive, motor, and language development of children in rural Bangladesh. Methods: In this cluster-randomised controlled trial, we enrolled pregnant women in their first or second trimester from rural villages of Gazipur, Kishoreganj, Mymensingh, and Tangail districts of central Bangladesh, with an average of eight women per cluster. Groups of eight geographically adjacent clusters were block-randomised, using a random number generator, into six intervention groups (all of which received weekly visits from a community health promoter for the first 6 months and every 2 weeks for the next 18 months) and a double-sized control group (no intervention or health promoter visit). 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 age 1 year, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at age 2 years. Masking of participants was not possible. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01590095. Findings: Between May 31, 2012, and July 7, 2013, 5551 pregnant women residing in 720 clusters were enrolled. Index children of 928 (17%) enrolled women were lost to follow-up in year 1 and an additional 201 (3%) in year 2. 4757 children were assessed at 1 year and 4403 at 2 years. At year 1, compared with the control group, the combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the standing alone milestone (hazard ratio 1·19, 95% CI 1·01–1 ·40), and the nutrition group had a higher rate of attaining the walking alone milestone (1·32, 95% CI 1·07–1·62). The combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the walking alone milestone than those in the water, sanitation, and handwashing group (1·29, 1·01–1·65). At 2 years, we noted beneficial effects in the combined EASQ score in all intervention groups, with effect sizes smallest in the water treatment group (difference 0·15, 95% CI 0·04 to 0·26 vs control) and largest in the combined water, sanitation, handwashing, and nutrition treatment group (0·37, 0·27–0·46). Interpretation: Improvements in water quality, handwashing, sanitation, or nutrition supported by intensive interpersonal communication, when delivered either individually or in combination, contributed to improvements in child development. A crucial next step is to establish whether similar effects can be achieved with reduced intensity of promoter contacts that could be supported in large-scale interventions. Funding: Bill & Melinda Gates Foundation.

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