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Randomized Controlled Trial
. 2025 Aug 7;113(4):888-902.
doi: 10.4269/ajtmh.24-0825. Print 2025 Oct 1.

The Impact and Sustainability of Multisector Interventions to Improve Water Quality and Food Safety in Complex Environments: A Cluster-Randomized Controlled Trial in Northern Uganda

Ian G Moore  1 , Yanlin Ren  1 , Stacy Griswold  1 , Carolyn Van Sant  1 , Camille Heylen  2 , Edgar Agaba  1 , Regina Brown  1 , Saurabh Mehta  3 , Balaji Srinivasan  3 , Gloria Desire Kayo  4 , Troshbert Mwesigire  4 , Marta Domini  2 , Jacqueline Namusalisi  4 , Daniele Lantagne  1   2 , Merry Fitzpatrick  1 , Anastasia Marshak  1 , Marlene Hebie  4 , Hugo De Groote  5 , Patrick Webb  1 , Shibani Ghosh  1   3
Affiliations
Randomized Controlled Trial

The Impact and Sustainability of Multisector Interventions to Improve Water Quality and Food Safety in Complex Environments: A Cluster-Randomized Controlled Trial in Northern Uganda

Ian G Moore et al. Am J Trop Med Hyg. .

Abstract

In complex environments characterized as protracted humanitarian settings where public services are largely lacking, food and water contamination are significant contributors to malnutrition. Multisector, multilevel, community-driven programs may address these issues simultaneously and synergistically. A 1:1:1 cluster randomized controlled design was used to evaluate the effectiveness of two social and behavior change interventions in northern Uganda aimed at enabling participants to assess and act on key drivers of malnutrition: a core nutrition impact and positive practice (NIPP) intervention versus an NIPP+ intervention, which included additional nudges toward adopting improved technologies, compared with a control arm (NCT04209569). Primary outcomes included concentrations of Escherichia coli (E. coli) and total coliform in household water (baseline n = 359), total maize aflatoxins (parts per billion; baseline n = 271), and women's serum aflatoxin B1-lysine (nanograms (ng)/mL and picograms (pg)/mg albumin, baseline n = 452). Data were collected at three time points: baseline (pre-intervention), endline (post-intervention), and sustainability (1 year post-intervention). The NIPP+ intervention, but not the NIPP intervention, significantly reduced the risk of household E. coli water contamination at endline (RR = 0.76; 95% CI = 0.59-0.97), but this effect was not sustained. No significant intervention effects on maize aflatoxins or serum aflatoxin B1 were found. These findings highlight the need to examine factors that prevent sustained water quality gains, including structural barriers to behavior change and innovation adoption. Additionally, intervention groups may not have received sufficient exposure to market vendors, leading to less adoption of new technologies. Future interventions may benefit from improved program implementation and strengthened market connections for obtaining technologies and selling agricultural products.

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Conflict of interest statement

Disclosures: S. Mehta is an unpaid board member for a diagnostic start-up focused on the measurement of nutritional biomarkers at the point of care, utilizing the results from his research in studies like the present one. Informed consent was obtained from all circle participants. Participants received a brief description of the work, potential risks and benefits of participation, privacy protection, and study contact information and were informed that they could leave the study at any time. Enumerators were recruited and trained on informed consent and data collection procedures in Agago, as described in the study protocol. The Institutional Review Board of the Tufts University Health Science Committee (FWA00004517) served as the primary US-based review board, and the Makerere University School of Public Health Research and Ethics Committee served as the primary review board in Uganda. Both boards reviewed and approved all protocols and amendments. The review boards of Cornell University, Centro Internacional de Mejoramiento de Maíz y Trigo (CIMMYT), the International Maize and Wheat Improvement Center, and the Uganda National Council for Science and Technology also reviewed and approved the protocol. Protocols were resubmitted annually to all review boards. In accordance with principled research ethics, children identified as having severe acute malnutrition during the anthropometric measurement activities associated with the study were referred to the local village health volunteer and a facility with adequate care provisioning for follow-up. The present study provided no cash or income-specific benefits to participants. This decision was based on the idea that participants benefited from the knowledge conveyed during the intervention, and that participants in the NIPP+ circles would also benefit from access to improved seeds and special bags for maize storage. The only costs incurred by participants were the time required to participate in the NIPP or NIPP+ intervention and the surveys or qualitative discussions.

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