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Randomized Controlled Trial
. 2020 Jun;102(6):1286-1295.
doi: 10.4269/ajtmh.19-0779.

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Jenna Swarthout  1 , Pavani K Ram  2 , Charles D Arnold  3 , Holly N Dentz  3 , Benjamin F Arnold  4 , Stephen Kalungu  5 , Audrie Lin  6 , Sammy M Njenga  7 , Christine P Stewart  3 , John M Colford  6 , Clair Null  8 , Amy J Pickering  1
Affiliations
Randomized Controlled Trial

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Jenna Swarthout et al. Am J Trop Med Hyg. 2020 Jun.

Abstract

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid-upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77-0.99], but no effect in the combined WSHN group weakens this finding.

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Conflict of interest statement

Disclosures: All authors received funding for salary or consulting fees and nonfinancial support through a grant from the Bill & Melinda Gates Foundation for this study. We declare no further competing interests. The trial is registered with ClinicalTrials.gov (NCT01704105).

Figures

Figure 1.
Figure 1.
Trial profile and analysis population for acute respiratory illness outcome.
Figure 2.
Figure 2.
Respiratory outcome prevalence ratios by treatment status, years 1 and 2 combined. This figure appears in color at www.ajtmh.org.
Figure 3.
Figure 3.
Respiratory outcome prevalence ratios by treatment status and year 1 only. This figure appears in color at www.ajtmh.org.
See this image and copyright information in PMC

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