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Water, sanitation, and hygiene for control of trachoma in Ethiopia (WUHA): a two-arm, parallel-group, cluster-randomised trial. Lancet Glob Health 2022; 10:e87-e95. [PMID: 34919861 PMCID: PMC9360557 DOI: 10.1016/s2214-109x(21)00409-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/13/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022]
Abstract
Background WHO promotes the SAFE strategy for the elimination of trachoma as a public health programme, which promotes surgery for trichiasis (ie, the S component), antibiotics to clear the ocular strains of chlamydia that cause trachoma (the A component), facial cleanliness to prevent transmission of secretions (the F component), and environmental improvements to provide water for washing and sanitation facilities (the E component). However, little evidence is available from randomised trials to support the efficacy of interventions targeting the F and E components of the strategy. We aimed to determine whether an integrated water, sanitation, and hygiene (WASH) intervention prevents the transmission of trachoma. Methods The WASH Upgrades for Health in Amhara (WUHA) was a two-arm, parallel-group, cluster-randomised trial in 40 rural communities in Wag Hemra Zone (Amhara Region, Ethiopia) that had been treated with 7 years of annual mass azithromycin distributions. The randomisation unit was the school catchment area. All households within a 1·5 km radius of a potential water point within the catchment area (as determined by the investigators) were eligible for inclusion. Clusters were randomly assigned (at a 1:1 ratio) to receive a WASH intervention either immediately (intervention) or delayed until the conclusion of the trial (control), in the absence of concurrent antibiotic distributions. Given the nature of the intervention, participants and field workers could not be masked, but laboratory personnel were masked to treatment allocation. The WASH intervention consisted of both hygiene infrastructure improvements (namely, construction of a community water point) and hygiene promotion by government, school, and community leaders, which were implemented at the household, school, and community levels. Hygiene promotion focused on two simple messages: to use soap and water to wash your or your child’s face, and to always use a latrine for defecation. The primary outcome was the cluster-level prevalence of ocular chlamydia, measured annually using conjunctival swabs in a random sample of children aged 0–5 years from each cluster at 12, 24, and 36 month timepoints. Analyses were done in an intention-to-treat manner. This trial is ongoing and is registered at ClinicalTrials.gov, NCT02754583. Findings Between Nov 9, 2015, and March 5, 2019, 40 of 44 clusters assessed for eligibility were enrolled and randomly allocated to the trial groups (20 clusters each, with 7636 people from 1751 households in the intervention group and 9821 people from 2211 households in the control group at baseline). At baseline, ocular chlamydia prevalence among children aged 0–5 years was 11% (95% CI 6 to 16) in the WASH group and 11% (5 to 18) in the control group. At month 36, ocular chlamydia prevalence had increased in both groups, to 32% (24 to 41) in the WASH group and 31% (21 to 41) in the control group (risk difference across three annual monitoring visits, after adjustment for prevalence at baseline: 3·7 percentage points; 95% CI −4·9 to 12·4; p=0·40). No adverse events were reported in either group. Interpretation An integrated WASH intervention addressing the F and E components of the SAFE strategy did not prevent an increase in prevalence of ocular chlamydia following cessation of antibiotics in an area with hyperendemic trachoma. The impact of WASH in the presence of annual mass azithromycin distributions is currently being studied in a follow-up trial of the 40 study clusters. Continued antibiotic distributions will probably be important in areas with persistent trachoma. Funding National Institutes of Health—National Eye Institute.
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Patlán‐Hernández AR, Stobaugh HC, Cumming O, Angioletti A, Pantchova D, Lapègue J, Stern S, N'Diaye DS. Water, sanitation and hygiene interventions and the prevention and treatment of childhood acute malnutrition: A systematic review. MATERNAL & CHILD NUTRITION 2022; 18:e13257. [PMID: 34612592 PMCID: PMC8710129 DOI: 10.1111/mcn.13257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/02/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Abstract
Undernutrition is more prevalent among children living in unsanitary environments with inadequate water, sanitation and hygiene (WASH). Despite good evidence for the effect of WASH on multiple infectious diseases, evidence for the effect of WASH interventions on childhood undernutrition is less well established, particularly for acute malnutrition. To assess the effectiveness of WASH interventions in preventing and treating acute childhood malnutrition, we performed electronic searches to identify relevant studies published between 1 January 2000 and 13 May 2019. We included studies assessing the effect of WASH on prevention and treatment of acute malnutrition in children under 5 years of age. Data were extracted by two independent reviewers. We included 26 articles of 599 identified references with a total of 43,083 participants. Twenty-five studies reported on the effect of WASH on prevention, and two studies reported its effect on treatment of acute malnutrition. Current evidence does not show consistent associations of WASH conditions and interventions with prevention of acute malnutrition or with the improvement of its treatment outcomes. Only two high-quality randomized controlled trials (RCTs) demonstrated that improved water quality during severe acute malnutrition treatment improved recovery outcomes but did not prevent relapse. Many of the interventions consisted of a package of WASH services, making impossible to attribute the effect to one specific component. This highlights the need for high-quality, rigorous intervention studies assessing the effects of WASH interventions specifically designed to prevent acute malnutrition or improve its treatment.
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Affiliation(s)
| | - Heather C. Stobaugh
- Action Against HungerNew YorkNew YorkUSA
- Tufts UniversityBostonMassachusettsUSA
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Danka Pantchova
- Action Contre la FaimParisFrance
- Global Nutrition ClusterUnited Nations Children's FundNew YorkNew YorkUSA
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Espira L, Aung T, Han K, Jagger P, Eisenberg JNS. Determinants of Pathogen Contamination of the Environment in the Greater Yangon Area, Myanmar. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:16465-16476. [PMID: 34792323 DOI: 10.1021/acs.est.1c02887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Recent results from water, sanitation, and hygiene interventions highlight the need to better understand environmental influences on enteropathogen transmission. We quantified a range of viral, bacterial, and protozoal pathogens and one indicator, Enterococcus faecalis in soil and water from urban and rural sites in and around Yangon, Myanmar. We found that environmental characteristics associated with contamination differed by pathogens and substrates. In soil, bacterial pathogen gene counts were associated with elevation and drainage ditches (compared to stagnant water) (RR = 0.96, 95% CI 0.93, 0.99 and RR = 1.70, 95% CI 1.18, 2.45, respectively), while viral gene counts were associated with the presence of sanitation facilities within 50 m of the collection point (RR = 3.99, 95% CI 1.12, 14.24). In water, E. faecalis, total pathogen, and bacterial pathogen gene counts were associated with drainage ditches (RR = 1.86, 95% CI 1.27, 2.72, RR = 1.38 95% CI 1.09, 1.74, and RR = 1.38 95% CI 1.07, 1.77, respectively). E. faecalis, total pathogen, bacterial pathogen, and viral gene counts were associated with the presence of uncollected garbage within 50 m of the collection point (RR = 1.57, 95% CI 1.00, 2.47, RR = 1.52, 95% CI 1.16, 2.00, RR = 1.52, 95% CI 1.13, 2.06, and RR = 1.75, 95% CI 1.17, 2.61 respectively). Measuring the environment provides added specificity toward identifying important environmental pathways that require mitigation.
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Affiliation(s)
- Leon Espira
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Ther Aung
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27516, United States
| | - Khin Han
- Department of Geography, West Yangon University, Yangon 13393, Myanmar
| | - Pamela Jagger
- School for Environment and Sustainability, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Joseph N S Eisenberg
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan 48109, United States
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Saaka M, Saapiire FN, Dogoli RN. Independent and joint contribution of inappropriate complementary feeding and poor water, sanitation and hygiene (WASH) practices to stunted child growth. J Nutr Sci 2021; 10:e109. [PMID: 35059190 PMCID: PMC8727702 DOI: 10.1017/jns.2021.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/14/2021] [Accepted: 11/28/2021] [Indexed: 11/07/2022] Open
Abstract
The causes of undernutrition are often linked to inappropriate complementary feeding practices and poor households' access to water, sanitation and hygiene (WASH), but limited evidence exists on the combined effect of poor WASH and inappropriate complementary feeding practices on stunted child growth. We assessed the independent and joint contribution of inappropriate complementary feeding and poor WASH practices to stunted growth among children aged 6-23 months in the Jirapa Municipality of Ghana. A community-based cross-sectional analytical study design was used with a sample of 301 mothers/caregivers having children aged 6-23 months. The results indicate that in a multivariable logistic regression model that adjusted for confounders, children receiving both unimproved water and inappropriate complementary feeding had a higher and significant odd of becoming stunted (adjusted odds ratio = 33. 92; 95 % confidence interval 3⋅04, 37⋅17; P = 0⋅004) compared to households having both improved water sources and appropriate complementary feeding practices. Except for unimproved drinking water sources, poor sanitation and hygiene, which comprised the use of unimproved household toilet facilities, washing hands without soap and improper disposal of child faeces were not associated with the risks of stunting among children aged 6-23 months. The combined effect of unimproved water and inappropriate complementary feeding on stunting was greater than either unimproved water only or inappropriate complementary feeding only.
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Affiliation(s)
- Mahama Saaka
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P. O. Box 1883, Tamale, Ghana
| | - Ferguson N Saapiire
- St. Joseph Nursing Training College, Ministry of Health, P. O. BOX 24, Jirapa, Wa, Ghana
| | - Richard N Dogoli
- Jhpiego Ghana, 14 Ollenu Street, East Legon, PMB 18, Legon Accra, Ghana
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged. Objectives Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews. Methods This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis. Results There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation. Conclusion Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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Rego R, Watson S, Alam MAU, Abdullah SA, Yunus M, Alam IT, Chowdhury AK, Haider S, Faruque ASG, Khan AI, Hofer T, Gill P, Islam MS, Lilford R. A comparison of traditional diarrhoea measurement methods with microbiological and biochemical indicators: A cross-sectional observational study in the Cox's Bazar displaced persons camp. EClinicalMedicine 2021; 42:101205. [PMID: 34849477 PMCID: PMC8608865 DOI: 10.1016/j.eclinm.2021.101205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Water, Sanitation, and Hygiene (WASH) systems aim to reduce the spread of enteric pathogens, particularly amongst children under five years old. The most common primary outcome of WASH trials is carer-reported diarrhoea. We evaluate different diarrhoea survey instruments as proxy markers of enteric pathogen presence in stool. METHODS We recruited 800 community-based participants from the Cox's Bazar Displaced Person's Camp in Bangladesh, split evenly between the rainy (July/August 2020) and dry (November/December 2020) periods. Participants were randomized evenly into either a standard survey asking carers if their child under five years old has had diarrhoea in the past fortnight, or a pictorial survey asking carers to pick from a pictorial chart which stools their child under five years old has had in the past fortnight. We collected stools from a random sub-sample of 120. Stools were examined visually, and tested for proteins associated with enteric infection and 16 enteric pathogens. We calculated sensitivities and specificities for each survey type, visual examination, and proteins with respect to enteric pathogen presence. FINDINGS The sensitivity of the standard survey for enteric pathogen presence was 0.49[95%CI:0.32,0.66] and the specificity was 0.65[0.41,0.85]. Similar sensitivities and specificities were observed for pictorial survey, visual inspection, and proteins. INTERPRETATION While diarrhoea is an important sign in clinical practice it appears that it is a poor proxy for enteric pathogen presence in stool in epidemiological surveys. When enteric infection is of interest, this should be measured directly. FUNDING The project was funded by the National Institutes for Health Research Global Health Research Unit on Improving Health in Slums (16/136/87) and by the University of Warwick.
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Affiliation(s)
- Ryan Rego
- Center for Global Health Equity, University of Michigan at Ann Arbor, USA
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | - Samuel Watson
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | | | | | - Mohammad Yunus
- International Center for Diarrhoeal Disease Research, Bangladesh
| | - Imam Taskin Alam
- International Center for Diarrhoeal Disease Research, Bangladesh
| | | | | | - ASG Faruque
- International Center for Diarrhoeal Disease Research, Bangladesh
| | | | - Timothy Hofer
- Center for Global Health Equity, University of Michigan at Ann Arbor, USA
| | - Paramjit Gill
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | | | - Richard Lilford
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
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Miller JD, Workman CL, Panchang SV, Sneegas G, Adams EA, Young SL, Thompson AL. Water Security and Nutrition: Current Knowledge and Research Opportunities. Adv Nutr 2021; 12:2525-2539. [PMID: 34265039 PMCID: PMC8634318 DOI: 10.1093/advances/nmab075] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/22/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022] Open
Abstract
Water is an essential nutrient that has primarily been considered in terms of its physiological necessity. But reliable access to water in sufficient quantities and quality is also critical for many nutrition-related behaviors and activities, including growing and cooking diverse foods. Given growing challenges to water availability and safety, including climate change, pollution, and infrastructure degradation, a broader conceptualization of water and its diverse uses is needed to sustainably achieve global nutrition targets. Therefore, we review empirical and qualitative evidence describing the linkages between water security (the reliable availability, accessibility, and quality of water for all household uses) and nutrition. Primary linkages include water security for drinking, food production and preparation, infant and young child feeding, and limiting exposure to pathogens and environmental toxins. We then identify knowledge gaps within each linkage and propose a research agenda for studying water security and nutrition going forward, including the concurrent quantification of both food and water availability, accessibility, use, and stability. By making explicit the connections between water security and nutritional well-being, we aim to promote greater collaboration between the nutrition and water, sanitation, and hygiene sectors. Interdisciplinary policies and programs that holistically address the water-nutrition nexus, versus those that focus on water and nutrition independently, are likely to significantly advance our ability to ensure equitable access to healthy foods and safe water for all.
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Affiliation(s)
- Joshua D Miller
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cassandra L Workman
- Department of Anthropology, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Sarita V Panchang
- Social Research and Evaluation Center, Louisiana State University, Baton Rouge, LA, USA
| | - Gretchen Sneegas
- Department of Geography, Texas A&M University, College Station, TX, USA
| | - Ellis A Adams
- Keough School of Global Affairs, University of Notre Dame, Notre Dame, IN, USA
| | - Sera L Young
- Department of Anthropology, Northwestern University, Evanston, IL, USA
- Institute for Policy Research, Northwestern University, Evanston, IL, USA
| | - Amanda L Thompson
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Han Y, Kim HB, Park S. The Roles of Nutrition Education and Food Vouchers in Improving Child Nutrition: Evidence from a Field Experiment in Ethiopia. JOURNAL OF HEALTH ECONOMICS 2021; 80:102545. [PMID: 34794009 DOI: 10.1016/j.jhealeco.2021.102545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/06/2021] [Accepted: 10/10/2021] [Indexed: 06/13/2023]
Abstract
Mothers' lack of knowledge about child nutrition and limited resources lead to poor diets among children in developing countries, increasing their risk of chronic undernutrition. We implemented a cluster randomized control trial that randomly provides four-month-long Behavior Change Communication (BCC) and food vouchers in Ethiopia. We find improvements in child-feeding practices and a reduction in chronic child undernutrition only when BCC and vouchers are provided together. BCC or voucher alone had limited impacts. Our results highlight the importance of adding an effective educational component to existing transfer programs.
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Affiliation(s)
- Yaeeun Han
- Institute for Emerging Market Studies, HKUST, Hong Kong.
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109
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Girma M, Hussein A, Norris T, Genye T, Tessema M, Bossuyt A, Hadis M, van Zyl C, Goyol K, Samuel A. Progress in Water, Sanitation and Hygiene (WASH) coverage and potential contribution to the decline in diarrhea and stunting in Ethiopia. MATERNAL & CHILD NUTRITION 2021:e13280. [PMID: 34738323 DOI: 10.1111/mcn.13280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/23/2021] [Accepted: 09/16/2021] [Indexed: 12/20/2022]
Abstract
Inadequate safe water supply and poor sanitation and hygiene continue to be important risk factors for diarrhoea and stunting globally. We used data from the four rounds of the Ethiopian Demographic and Health Survey and applied the new World Health Organization (WHO)/UNICEF Joint Monitoring Program (JMP) service standards to assess progress in water, sanitation and hygiene (WASH) coverage between 2000 and 2016. We also performed an age-disaggregated pooled linear probability regression analysis followed by a decomposition analysis to determine whether changes in WASH practices have contributed to the changing prevalence of diarrhoea and stunting in children under 5 years of age. We observed a significant increase in the coverage of safe drinking water and adequate sanitation facilities over the period. At the national level, the use of a basic water source increased from 18% in 2000 to 50% in 2016. Open defecation declined from 82% to 32% over the same period. However, in 2016, only 6% of households had access to a basic sanitation facility, and 40% of households had no handwashing facilities. The reduction in surface water use between 2000 and 2016 explained 6% of the decline in diarrhoea observed among children aged 0-5 months. In children aged 6-59 months, between 7% and 9% of the reduction in stunting were attributable to the reduction in open defecation over this period. Despite progress, improvements are still needed to increase basic WASH coverage in Ethiopia. Our findings showed that improvements in water and sanitation only modestly explained reductions in diarrhoea and stunting.
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Affiliation(s)
- Meron Girma
- National Information Platforms for Nutrition (NIPN), Ethiopian Public Health Institute, Arbegnoch Street, Addis Ababa, 1242, Ethiopia
| | - Alemayehu Hussein
- National Information Platforms for Nutrition (NIPN), Ethiopian Public Health Institute, Arbegnoch Street, Addis Ababa, 1242, Ethiopia
| | - Tom Norris
- National Information Platforms for Nutrition (NIPN) Collaborator, International Food Policy Research Institute, Addis Ababa, Ethiopia
| | - Tirsit Genye
- National Information Platforms for Nutrition (NIPN), International Food Policy Research Institute, Addis Ababa, Ethiopia
| | - Masresha Tessema
- National Information Platforms for Nutrition (NIPN), Ethiopian Public Health Institute, Arbegnoch Street, Addis Ababa, 1242, Ethiopia
| | - Anne Bossuyt
- National Information Platforms for Nutrition (NIPN), International Food Policy Research Institute, Addis Ababa, Ethiopia
| | - Mamuye Hadis
- Knowledge Translation Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Cornelia van Zyl
- National Information Platforms for Nutrition (NIPN), International Food Policy Research Institute, Addis Ababa, Ethiopia
| | - Kitka Goyol
- Water, Sanitation and Hygiene (WASH), UNICEF, Addis Ababa, Ethiopia
| | - Aregash Samuel
- National Information Platforms for Nutrition (NIPN), Ethiopian Public Health Institute, Arbegnoch Street, Addis Ababa, 1242, Ethiopia
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Dewey KG, Wessells KR, Arnold CD, Prado EL, Abbeddou S, Adu-Afarwuah S, Ali H, Arnold BF, Ashorn P, Ashorn U, Ashraf S, Becquey E, Bendabenda J, Brown KH, Christian P, Colford JM, Dulience SJL, Fernald LCH, Galasso E, Hallamaa L, Hess SY, Humphrey JH, Huybregts L, Iannotti LL, Jannat K, Lartey A, Le Port A, Leroy JL, Luby SP, Maleta K, Matias SL, Mbuya MNN, Mridha MK, Nkhoma M, Null C, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Prendergast AJ, Ruel M, Shaikh S, Weber AM, Wolff P, Zongrone A, Stewart CP. Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2021; 114:15S-42S. [PMID: 34590672 PMCID: PMC8560308 DOI: 10.1093/ajcn/nqab278] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.
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Affiliation(s)
- Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Hasmot Ali
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sania Ashraf
- Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, PA, USA
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Jaden Bendabenda
- Department of Nutrition and Food Safety, WHO, Geneva, Switzerland
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
- Helen Keller International, New York, NY, USA
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Jean H Humphrey
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Kaniz Jannat
- School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Minyanga Nkhoma
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Harriet Okronipa
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
| | | | | | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Marie Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Saijuddin Shaikh
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | | | | | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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Vande Velde F, Overgaard HJ, Bastien S. Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment. PLoS Negl Trop Dis 2021; 15:e0009239. [PMID: 34723983 PMCID: PMC8584752 DOI: 10.1371/journal.pntd.0009239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 11/11/2021] [Accepted: 10/13/2021] [Indexed: 12/19/2022] Open
Abstract
Background Nudging, a strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion. Methods A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations. Results This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience. Conclusion Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of ‘what works’ and ‘how it works’. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC. Behavior is at the core of neglected tropical disease (NTD) prevention and control, certainly within low-, and middle- income countries (LMIC) where resources are often limited. Therefore, strategies to promote behavior change should be included and investigated in future efforts. Nudging, a low-cost strategy that subtly directs people towards positive behavioral choices, has recently gained attention in global health promotion. Nudge strategies have been applied to a wide range of health-promoting behaviors such as handwashing. To understand which strategies were used, where and how these were applied, and whether these were ethically informed and implemented, we undertook a comprehensive review of the available sources. This resulted in 33 included studies, with a total of 67 nudge strategies for behavior-based prevention and control of NTDs in LMIC. Only two studies targeted NTDs in particular, the other 31 included studies were focused on more general health promoting behaviors, with the majority targeting handwashing with soap. The most common nudge strategies were those targeting decision assistance, such as fostering commitment and reminder actions. In general, the ethical assessment presented favorable results. We identified the need for robust study designs to better understand how nudges can be implemented in the future.
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Affiliation(s)
- Fiona Vande Velde
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
- * E-mail:
| | - Hans J. Overgaard
- Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway
- Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sheri Bastien
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- The Centre for Evidence-Based Public Health: A JBI Affiliated Group, Department of Public Health Science, NMBU, Ås, Norway
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Prado EL, Arnold CD, Wessells KR, Stewart CP, Abbeddou S, Adu-Afarwuah S, Arnold BF, Ashorn U, Ashorn P, Becquey E, Brown KH, Chandna J, Christian P, Dentz HN, Dulience SJL, Fernald LC, Galasso E, Hallamaa L, Hess SY, Huybregts L, Iannotti LL, Jimenez EY, Kohl P, Lartey A, Le Port A, Luby SP, Maleta K, Matchado A, Matias SL, Mridha MK, Ntozini R, Null C, Ocansey ME, Parvez SM, Phuka J, Pickering AJ, Prendergast AJ, Shamim AA, Siddiqui Z, Tofail F, Weber AM, Wu L, Dewey KG. Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers. Am J Clin Nutr 2021; 114:43S-67S. [PMID: 34590116 PMCID: PMC8560311 DOI: 10.1093/ajcn/nqab277] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.
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Affiliation(s)
- Elizabeth L Prado
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Christine P Stewart
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Kenneth H Brown
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
- Helen Keller International, New York, NY, USA
| | - Jaya Chandna
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Holly N Dentz
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sonja Y Hess
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Elizabeth Y Jimenez
- Departments of Pediatrics and Internal Medicine and College of Population Health, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Patricia Kohl
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Matchado
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | - Sarker M Parvez
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - John Phuka
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Abu A Shamim
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Zakia Siddiqui
- Healthy Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Fahmida Tofail
- Nutrition and Clinical Sciences Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | - Lee S F Wu
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
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Aragie S, Tadesse W, Dagnew A, Hailu D, Dubie M, Wittberg DM, Melo JS, Haile M, Zeru T, Freeman MC, Nash SD, Callahan EK, Tadesse Z, Arnold BF, Porco TC, Lietman TM, Keenan JD. Changing hygiene behaviours: a cluster-randomized trial, Ethiopia. Bull World Health Organ 2021; 99:762-772A. [PMID: 34737469 PMCID: PMC8542271 DOI: 10.2471/blt.21.285915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether a water, sanitation and hygiene intervention could change hygiene behaviours thought to be important for trachoma control. METHODS We conducted a cluster-randomized trial in rural Ethiopia from 9 November 2015 to 5 March 2019. We randomized 20 clusters to an intervention consisting of water and sanitation infrastructure and hygiene promotion and 20 clusters to no intervention. All intervention clusters received a primary-school hygiene curriculum, community water point, household wash station, household soap and home visits from hygiene promotion workers. We assessed intervention fidelity through annual household surveys. FINDINGS Over the 3 years, more wash stations, soap and latrines were seen at households in the intervention clusters than the control clusters: risk difference 47 percentage points (95% confidence interval, CI: 41-53) for wash stations, 18 percentage points (95% CI: 12-24) for soap and 12 percentage points (95% CI: 5-19) for latrines. A greater proportion of people in intervention clusters reported washing their faces with soap (e.g. risk difference 21 percentage points; 95% CI: 15-27 for 0-5 year-old children) and using a latrine (e.g. risk difference 9 percentage points; 95% CI: 2-15 for 6-9 year-old children). Differences between the intervention and control arms were not statistically significant for many indicators until the programme had been implemented for at least a year; they did not decline during later study visits. CONCLUSION The community- and school-based intervention was associated with improved hygiene access and behaviours, although changes in behaviour were slow and required several years of the intervention.
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Affiliation(s)
| | | | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | - Melese Dubie
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | - Dionna M Wittberg
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jason S Melo
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | | | - Taye Zeru
- Amhara Public Health Institute, Bahir Dar, Ethiopia
| | | | | | | | | | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Travis C Porco
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
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Dolstad HA, Franke MF, Vissieres K, Jerome JG, Ternier R, Ivers LC. Factors associated with diarrheal disease among children aged 1-5 years in a cholera epidemic in rural Haiti. PLoS Negl Trop Dis 2021; 15:e0009726. [PMID: 34679083 PMCID: PMC8535179 DOI: 10.1371/journal.pntd.0009726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 08/12/2021] [Indexed: 11/18/2022] Open
Abstract
Diarrheal illness is a major cause of morbidity and mortality among children in Haiti, and the impact of diarrheal illness was compounded by a cholera outbreak between 2010 and 2019. Our understanding of risk factors for diarrhea among children during this outbreak is limited. We conducted a secondary analysis of data collected as part of a cholera vaccine effectiveness study to identify factors associated with medically attended diarrhea among children in central Haiti from October of 2012 through November of 2016. We identified 47 children aged one to five years old who presented to medical clinics with acute, watery diarrhea, and 166 matched controls who did not have diarrhea, and we performed conditional logistic regression to identify factors associated with diarrhea. Discontinuing exclusive breastfeeding within one month of birth was associated with increased risk of diarrhea (RR 6.9, 95% CI 1.46–32.64), and diarrhea was inversely associated with reported history of supplementation with vitamin A (RR 0.05, 95% CI 0.004–0.56) and zinc (reported among 0% of cases vs. 17% of controls). Because of the concordance in supplementation patterns, it was not possible to attribute the association to vitamin A or zinc independently. While having a respondent who correctly identified ≥3 means of avoiding cholera was associated with reduced risk of diarrhea (RR 0.43, 95% CI 0.19–1.01), reported household sanitation practices and knowledge of cholera were not consistently associated with risk of diarrhea. These findings support ongoing efforts to reduce barriers to breastfeeding and promote pediatric supplementation with vitamin A and zinc in Haiti. Given the reduced efficacy of current oral cholera vaccines (OCV) among children, the results reinforce the importance of breastfeeding and micronutrient supplementation in preventing all-cause pediatric diarrheal illness generally and during cholera outbreaks. Diarrheal diseases are leading causes of illness and death among children throughout the world, and children in Haiti were particularly impacted by diarrhea during the cholera outbreak that started in 2010. Between 2012 and 2016, data were collected as part of a case-control study of oral cholera vaccine (OCV) effectiveness in Haiti. We analyzed data from that study to identify factors associated with diarrheal illness, including cholera and non-cholera diarrhea, among children ages one through five years old. We found a direct association between longer duration of exclusive breastfeeding and supplementation with vitamin A and zinc and a reduced risk of diarrhea. These findings shed light on potentially important components of efforts to reduce pediatric diarrheal illness in Haiti generally, and to reduce pediatric diarrhea in the context of cholera outbreaks in Haiti and elsewhere.
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Affiliation(s)
- Hilary A. Dolstad
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | - Louise C. Ivers
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program). Int J Hyg Environ Health 2021; 238:113850. [PMID: 34673353 DOI: 10.1016/j.ijheh.2021.113850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
Abstract
Diarrheal disease remains a leading cause of child mortality, globally. In the Democratic Republic of the Congo (DRC), each year there are an estimated 45 million episodes of diarrhea in children under five years of age. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to develop theory-driven, evidence-based approaches to reduce diarrheal diseases among young children. The REDUCE prospective cohort study in Walungu Territory in Eastern DRC took guidance from the risks, attitudes, norms, abilities, and self-regulation model, the integrated behavioral model for water, sanitation, and hygiene (WASH), and other behavior change theories to identify psychosocial factors associated with WASH behaviors. Psychosocial factors were measured among 417 caregivers at baseline and caregiver responses to child mouthing of dirty fomites and handwashing with soap was assessed by 5-hour structured observation at the 6-month follow-up. Caregivers who agreed that their child could become sick if they put dirt in their mouth (perceived susceptibility) and caregivers that agreed they could prevent their child from playing with dirty things outside (self-efficacy) were significantly more likely to stop their child from mouthing a dirty fomite. Higher perceived susceptibility, self-efficacy, and disgust, and lower dirty reactivity, were associated with higher handwashing with soap behaviors. This study took a theory-driven and evidence-based approach to identify psychosocial factors to target for intervention development. The findings from this study informed the development of the REDUCE Baby WASH Modules that have been delivered to over 1 million people in eastern DRC.
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Platts-Mills JA, Rogawski McQuade ET. Shigellosis in young children in low-income and middle-income countries: insights from molecular diagnostics. Curr Opin Infect Dis 2021; 34:463-470. [PMID: 34261903 DOI: 10.1097/qco.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe the impact of molecular diagnostics on our understanding of the burden and epidemiology of shigellosis in children in low-income and middle-income countries. RECENT FINDINGS The incorporation of molecular diagnostics has led to a substantial increase in estimates of the burden of shigellosis and have allowed for further resolution of other aspects of Shigella epidemiology, including the clinical characteristics of shigellosis, the association between clinical and subclinical Shigella infection and linear growth shortfalls, protection after natural infection, duration of convalescent shedding, and host determinants of susceptibility. SUMMARY The increased sensitivity and precision afforded by molecular approaches has represented a major advance in our understanding of the epidemiology and burden of shigellosis in the settings of highest importance.
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Affiliation(s)
- James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, Virginia, USA
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Dewey KG, Stewart CP, Wessells KR, Prado EL, Arnold CD. Small-quantity lipid-based nutrient supplements for the prevention of child malnutrition and promotion of healthy development: overview of individual participant data meta-analysis and programmatic implications. Am J Clin Nutr 2021; 114:3S-14S. [PMID: 34590696 PMCID: PMC8560310 DOI: 10.1093/ajcn/nqab279] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 08/04/2021] [Indexed: 12/14/2022] Open
Abstract
Small-quantity lipid-based nutrient supplements (SQ-LNSs) were designed to provide multiple micronutrients within a food base that also provides energy, protein, and essential fatty acids, targeted towards preventing malnutrition in vulnerable populations. Previous meta-analyses demonstrated beneficial effects of SQ-LNSs on child growth, anemia, and mortality. To further examine the efficacy and effectiveness of SQ-LNSs, and explore study-level and individual-level effect modifiers, we conducted an individual participant data meta-analysis of 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n > 37,000). We examined growth, development, anemia, and micronutrient status outcomes. Children who received SQ-LNSs had a 12-14% lower prevalence of stunting, wasting, and underweight; were 16-19% less likely to score in the lowest decile for language, social-emotional, and motor development; had a 16% lower prevalence of anemia; and had a 64% lower prevalence of iron-deficiency anemia compared with control group children. For most outcomes, beneficial effects of SQ-LNSs were evident regardless of study-level characteristics, including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average reported compliance with SQ-LNSs. For development, the benefits of SQ-LNSs were greater in populations with higher stunting burden, in households with lower socioeconomic status, and among acutely malnourished children. For hemoglobin and iron status, benefits were greater in populations with higher anemia prevalence and among acutely malnourished children, respectively. Thus, targeting based on potential to benefit may be worthwhile for those outcomes. Overall, co-packaging SQ-LNSs with interventions that reduce constraints on response, such as the prevention and control of prenatal and child infections, improving health care access, and promotion of early child development, may lead to greater impact. Policymakers and program planners should consider including SQ-LNSs in strategies to reduce child mortality, stunting, wasting, anemia, iron deficiency, and delayed development. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592, CRD42020159971, and CRD42020156663.
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Affiliation(s)
| | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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Wessells KR, Arnold CD, Stewart CP, Prado EL, Abbeddou S, Adu-Afarwuah S, Arnold BF, Ashorn P, Ashorn U, Becquey E, Brown KH, Byrd KA, Campbell RK, Christian P, Fernald L, Fan YM, Galasso E, Hess SY, Huybregts L, Jorgensen JM, Kiprotich M, Kortekangas E, Lartey A, Le Port A, Leroy JL, Lin A, Maleta K, Matias SL, Mbuya M, Mridha MK, Mutasa K, Naser AM, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Rahman M, Schulze K, Smith LE, Weber AM, Zongrone A, Dewey KG. Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child anemia and micronutrient status: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2021; 114:68S-94S. [PMID: 34590114 PMCID: PMC8560313 DOI: 10.1093/ajcn/nqab276] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Small-quantity lipid-based nutrient supplements (SQ-LNSs) have been shown to reduce the prevalence of child anemia and iron deficiency, but effects on other micronutrients are less well known. Identifying subgroups who benefit most from SQ-LNSs could support improved program design. OBJECTIVES We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child hemoglobin (Hb), anemia, and inflammation-adjusted micronutrient status outcomes. METHODS We conducted a 2-stage meta-analysis of individual participant data from 13 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 15,946). We generated study-specific and subgroup estimates of SQ-LNSs compared with control, and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine potential study-level effect modifiers. RESULTS SQ-LNS provision decreased the prevalence of anemia (Hb < 110 g/L) by 16% (relative reduction), iron deficiency (plasma ferritin < 12 µg/L) by 56%, and iron deficiency anemia (IDA; Hb < 110 g/L and plasma ferritin <12 µg/L) by 64%. We observed positive effects of SQ-LNSs on hematological and iron status outcomes within all subgroups of the study- and individual-level effect modifiers, but effects were larger in certain subgroups. For example, effects of SQ-LNSs on anemia and iron status were greater in trials that provided SQ-LNSs for >12 mo and provided 9 (as opposed to <9) mg Fe/d, and among later-born (than among first-born) children. There was no effect of SQ-LNSs on plasma zinc or retinol, but there was a 7% increase in plasma retinol-binding protein (RBP) and a 56% reduction in vitamin A deficiency (RBP < 0.70 µmol/L), with little evidence of effect modification by individual-level characteristics. CONCLUSIONS SQ-LNSs can substantially reduce the prevalence of anemia, iron deficiency, and IDA among children across a range of individual, population, and study design characteristics. Policy-makers and program planners should consider SQ-LNSs within intervention packages to prevent anemia and iron deficiency.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020156663.
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Affiliation(s)
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA,Helen Keller International, New York, NY, USA
| | | | - Rebecca K Campbell
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Yue-Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Josh M Jorgensen
- Nutrition Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | | | - Emma Kortekangas
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Audrie Lin
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Abu M Naser
- International Center for Diarrheal Diseases Research (icddr,b), Dhaka, Bangladesh,Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Harriet Okronipa
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
| | | | | | - Mahbubur Rahman
- International Center for Diarrheal Diseases Research (icddr,b), Dhaka, Bangladesh
| | - Kerry Schulze
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura E Smith
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | | | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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120
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Smith DW, Sultana S, Crider YS, Islam SA, Swarthout JM, Goddard FGB, Rabbani A, Luby SP, Pickering AJ, Davis J. Effective Demand for In-Line Chlorination Bundled with Rental Housing in Dhaka, Bangladesh. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:12471-12482. [PMID: 34498866 DOI: 10.1021/acs.est.1c01308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Delivering safe water in cities of lower- and middle-income countries remains elusive even where there is a piped supply. Passive, in-line chlorination upstream of the point of water collection reduces child diarrhea without the behavior change required for point-of-use water treatment products or manual chlorine dispensers. We conducted a price experiment to measure effective demand (willingness and ability to pay) for an in-line chlorination service using tablet chlorinators among 196 landlords of rental housing properties in Dhaka, Bangladesh. We offered a 12-month subscription using Becker-DeGroot-Marschak auctions with real money payments. The service consistently delivered chlorinated water and satisfied tenants. Landlords' effective demand for in-line chlorination was similar to or greater than that for point-of-use treatment products and manual chlorine dispensers previously documented among Dhaka households. Over the service period, landlords renting to low-income households had lower effective demand than those renting to middle-income households despite similar initial rates of payment across both groups. Making in-line chlorination financially viable for the lowest-income consumers would likely require service cost reductions, subsidies, or both. Our findings suggest that even revealed preference experiments may overestimate the effective demand needed to sustain water supply improvements, especially in low-income populations, if they only measure demand once.
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Affiliation(s)
- Daniel W Smith
- Department of Civil & Environmental Engineering, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
| | - Sonia Sultana
- Environmental Interventions Unit, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Yoshika S Crider
- Department of Civil & Environmental Engineering, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
| | - Syed Anjerul Islam
- Environmental Interventions Unit, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Jenna M Swarthout
- Department of Civil & Environmental Engineering, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
| | - Frederick G B Goddard
- Department of Civil & Environmental Engineering, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
| | - Atonu Rabbani
- Department of Economics, University of Dhaka, Dhaka 1000, Bangladesh
- BRAC James P. Grant School of Public Health, BRAC University, 66 Mohakhali, Dhaka 1212, Bangladesh
| | - Stephen P Luby
- Stanford Woods Institute for the Environment, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
| | - Amy J Pickering
- Department of Civil & Environmental Engineering, Davis Hall, University of California, Berkeley, Berkeley, California 94720, United States
| | - Jennifer Davis
- Department of Civil & Environmental Engineering, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
- Stanford Woods Institute for the Environment, Stanford University, Y2E2 Building, 473 Via Ortega, Stanford, California 94305, United States
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121
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Holcomb DA, Knee J, Capone D, Sumner T, Adriano Z, Nalá R, Cumming O, Brown J, Stewart JR. Impacts of an Urban Sanitation Intervention on Fecal Indicators and the Prevalence of Human Fecal Contamination in Mozambique. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:11667-11679. [PMID: 34382777 PMCID: PMC8429117 DOI: 10.1021/acs.est.1c01538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Fecal source tracking (FST) may be useful to assess pathways of fecal contamination in domestic environments and to estimate the impacts of water, sanitation, and hygiene (WASH) interventions in low-income settings. We measured two nonspecific and two human-associated fecal indicators in water, soil, and surfaces before and after a shared latrine intervention from low-income households in Maputo, Mozambique, participating in the Maputo Sanitation (MapSan) trial. Up to a quarter of households were impacted by human fecal contamination, but trends were unaffected by improvements to shared sanitation facilities. The intervention reduced Escherichia coli gene concentrations in soil but did not impact culturable E. coli or the prevalence of human FST markers in a difference-in-differences analysis. Using a novel Bayesian hierarchical modeling approach to account for human marker diagnostic sensitivity and specificity, we revealed a high amount of uncertainty associated with human FST measurements and intervention effect estimates. The field of microbial source tracking would benefit from adding measures of diagnostic accuracy to better interpret findings, particularly when FST analyses convey insufficient information for robust inference. With improved measures, FST could help identify dominant pathways of human and animal fecal contamination in communities and guide the implementation of effective interventions to safeguard health.
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Affiliation(s)
- David A. Holcomb
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States of America
| | - Jackie Knee
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332, United States of America
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Drew Capone
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States of America
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332, United States of America
| | - Trent Sumner
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332, United States of America
| | | | - Rassul Nalá
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States of America
| | - Jill R. Stewart
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States of America
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122
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Singh P, Shah M, Bruckner TA. Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India. J Nutr 2021; 151:2455-2464. [PMID: 34143878 PMCID: PMC8436001 DOI: 10.1093/jn/nxab150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition. OBJECTIVES We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India. METHODS In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates. RESULTS Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM. CONCLUSIONS An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.
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Affiliation(s)
- Parvati Singh
- Program in Public Health, University of
California, Irvine, Irvine, CA,
USA
| | - Manisha Shah
- Department of Public Policy, Luskin School of Public Affairs,
University of California, Los Angeles, Los
Angeles, CA, USA
| | - Tim A Bruckner
- Program in Public Health, University of
California, Irvine, Irvine, CA,
USA
- Center for Population, Inequality and Policy, University of
California, Irvine, Irvine, CA,
USA
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123
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Alfonso Mayén V, Ogunlusi A, Wright CM, Garcia AL. Childhood stunting and micronutrient status unaffected by RCT of micronutrient fortified drink. MATERNAL AND CHILD NUTRITION 2021; 18:e13256. [PMID: 34355514 PMCID: PMC8710120 DOI: 10.1111/mcn.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 12/02/2022]
Abstract
Micronutrient supplementation is widely used to prevent stunting in children under 5 years in low‐ and middle‐income countries (LMIC), but the impact of treatment has been disappointing, possibly due to non‐compliance. Our aim was to deliver long‐term micronutrient supplementation via a novel, culturally acceptable liquid food to improve linear growth in a high stunting prevalence region. In a randomised control trial, 971 children aged 6–72 months received either ‘Chispuditos®’ (n = 681), a hot drink (atole) fortified with micronutrients (atole + MN) (9 mg/zinc, 12.5 mg/iron), or lactose‐free milk (n = 290) for 18 months. Primary outcomes were changes in length/height‐for‐age (HAZ) score and the prevalence of stunting at 18‐month follow‐up. Adherence was monitored monthly, and 73% children in atole + MN group consumed at least half their daily zinc and iron requirement. At 18 months, there was no difference between the treatments in growth [mean change in HAZ −0.02 (95% CI −0.12, 0.08)] or stunting [atole + MN 41%, milk 41%; RR 0.99 (95% CI 0.84, 1.19)]. There were no differences in haemoglobin (HB), ferritin or zinc. No children had iron deficiency anaemia (IDA) at outcome, but zinc deficiency remained equally prevalent in both groups: atole + MN 35%, milk 35% [RR 1.02 (95% CI 0.83, 1.24)]. There was no difference in morbidity between the groups, and micronutrient status was unrelated to HAZ. Long‐term micronutrient supplementation via a culturally acceptable food had no impact on stunting or morbidity, raising the question of whether large‐scale micronutrient supplementation is worthwhile.
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Affiliation(s)
- Victor Alfonso Mayén
- Association for the Prevention and Study of HIV/AIDS (APEVIHS), Retalhuleu, Guatemala
| | - Abimbola Ogunlusi
- Human Nutrition, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Charlotte Margaret Wright
- Department of Child Health, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Ada Lizbeth Garcia
- Human Nutrition, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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Mutoro AN, Garcia AL, Kimani-Murage EW, Wright CM. Prevalence and overlap of known undernutrition risk factors in children in Nairobi Kenya. MATERNAL AND CHILD NUTRITION 2021; 18:e13261. [PMID: 34355500 PMCID: PMC8710128 DOI: 10.1111/mcn.13261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/01/2022]
Abstract
We aimed to describe the co‐occurrence of known risk factors for undernutrition and the prevalence of modifiable risks in wasted, stunted and healthy children. Quota sampling was used to recruit healthy [weight for age Z scores (WAZ) > −2 SD] and undernourished [weight for length (WLZ) or WAZ scores ≤ −2 SD] children aged 6–24 months from seven clinics in low‐income areas of Nairobi. Structured interviews were used to identify exposure to socioeconomic, water and hygiene, infant feeding, dietary and behavioural risks (low interest in food, high food refusal and force feeding). We recruited 92 wasted WLZ ≤ −2 SD, 133 stunted (length for age Z scores LAZ ≤ −2 SD) and 172 healthy (LAZ and WLZ > 2SD) children. Nearly all children were exposed to hygiene risks (90%) and low dietary diversity (95%) regardless of nutritional status. Stunted children were more likely to be exposed to socio‐economic risks (54% healthy, 64% wasted and 72% stunted; P = 0.001). Compared with healthy children, wasted and stunted children were more likely to be exposed to infant feeding (25% healthy, 40% wasted and 41% stunted; P = 0.02) and behaviour risks (24% healthy, 49% wasted, and 44% stunted; P = 0.004). Overall, wasted and stunted children were twice as likely to be exposed to more than three risks (23% healthy, 48% wasted, and 50% stunted; P = <0.001). They were also more likely to be exposed to more than three modifiable risks (dietary, handwashing and behaviour risks). Wasting and stunting are associated with exposure to multiple risk factors, many of which are potentially modifiable using targeted advice.
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Affiliation(s)
- Antonina N Mutoro
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.,Maternal and Child Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Ada L Garcia
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Elizabeth W Kimani-Murage
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.,Maternal and Child Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
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125
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Capone D, Berendes D, Cumming O, Holcomb D, Knee J, Konstantinidis KT, Levy K, Nalá R, Risk BB, Stewart J, Brown J. Impact of an Urban Sanitation Intervention on Enteric Pathogen Detection in Soils. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:9989-10000. [PMID: 34236178 PMCID: PMC8327413 DOI: 10.1021/acs.est.1c02168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Environmental fecal contamination is common in many low-income cities, contributing to a high burden of enteric infections and associated negative sequelae. To evaluate the impact of a shared onsite sanitation intervention in Maputo, Mozambique on enteric pathogens in the domestic environment, we collected 179 soil samples at shared latrine entrances from intervention (n = 49) and control (n = 51) compounds during baseline (preintervention) and after 24 months (postintervention) as part of the Maputo Sanitation Trial. We tested soils for the presence of nucleic acids associated with 18 enteric pathogens using a multiplex reverse transcription qPCR platform. We detected at least one pathogen-associated gene target in 91% (163/179) of soils and a median of 3 (IQR = 1, 5) pathogens. Using a difference-in-difference analysis and adjusting for compound population, visibly wet soil, sun exposure, wealth, temperature, animal presence, and visible feces, we estimate the intervention reduced the probability of detecting ≥1 pathogen gene by 15% (adjusted prevalence ratio, aPR = 0.85; 95% CI: 0.70, 1.0) and the total number of pathogens by 35% (aPR = 0.65; 0.44, 0.95) in soil 24 months following the intervention. These results suggest that the intervention reduced the presence of some fecal contamination in the domestic environment, but pathogen detection remained prevalent 24 months following the introduction of new latrines.
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Affiliation(s)
- Drew Capone
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - David Berendes
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Holcomb
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jackie Knee
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Konstantinos T. Konstantinidis
- Civil and Environmental Engineering, Georgia Institute of Technology, 311 Ferst Drive, Atlanta, Georgia, United States of America
| | - Karen Levy
- Environmental and Occupational Health Sciences, University of Washington, 2980 15th Ave NE, Seattle, Washington, United States of America
| | - Rassul Nalá
- Ministério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Benjamin B. Risk
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, United States of America
| | - Jill Stewart
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Choudhary N, Schuster RC, Brewis A, Wutich A. Household Water Insecurity Affects Child Nutrition Through Alternative Pathways to WASH: Evidence From India. Food Nutr Bull 2021; 42:170-187. [PMID: 34282660 DOI: 10.1177/0379572121998122] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Household water security matters greatly for child nutrition outcomes in the global South. Water's role in sanitation/hygiene, via diarrheal disease, is cited as a primary mechanism here. Yet, the relationship between Water along with Sanitation and Hygiene (WASH) and child stunting remains inconclusive. Water-related mechanisms outside of the traditional scope of WASH might assist with explaining this. OBJECTIVE We aim to test the mediating role of reduced dietary diversity as an additional potential mechanism in linking worse household water access to increased risk of early childhood stunting, separating its effects from sanitation and diarrhea among children (as a proxy for hygiene) and taking into account regional water availability. METHOD We use nationally representative India Demographic and Health Survey (2015-16) data for 58 038 children aged 6 to 23 months, applying generalized structural equation modelling to estimate water's direct and indirect effects (as mediated through dietary diversity and access to sanitation) on a child's likelihood of being stunted. RESULTS Suboptimal water access is significantly associated with elevated likelihood of child stunting. More than 30% of the effect is indirect. In the context of low water access and availability, children's dietary diversity alone mediates more than 20% of its total effect on child stunting. CONCLUSION Beyond the WASH mechanisms, household water access affects child stunting indirectly, mediated through its impacts on children's dietary diversity. These mediating effects are also moderated by regional water availability. Water interventions in low-water regions should help reduce children's risk of nutrition-related stunting in households with lowest water access.
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127
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Budge S, Hutchings P, Parker A, Tyrrel S, Norton S, Garbutt C, Woldemedhin F, Jemal MY, Moges M, Hussen S, Beyene H. A randomised controlled feasibility trial of a BabyWASH household playspace: The CAMPI study. PLoS Negl Trop Dis 2021; 15:e0009514. [PMID: 34260591 PMCID: PMC8312948 DOI: 10.1371/journal.pntd.0009514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 07/26/2021] [Accepted: 05/28/2021] [Indexed: 11/26/2022] Open
Abstract
Background Water, sanitation and hygiene (WASH) interventions should support infant growth but trial results are inconsistent. Frequently, interventions do not consider behaviours or transmission pathways specific to age. A household playspace (HPS) is one intervention component which may block faecal-oral transmission. This study was a two-armed, parallel-group, randomised, controlled feasibility trial of a HPS in rural Ethiopia. It aimed to recommend proceeding to a definitive trial. Secondary outcomes included effects on infant health, injury prevention and women’s time. Methods November 2019−January 2020 106 households were identified and assessed for eligibility. Recruited households (N = 100) were randomised (blinded prior to the trial start) to intervention or control (both n = 50). Outcomes included recruitment, attrition, adherence, and acceptability. Data were collected at baseline, two and four weeks. Findings Recruitment met a priori criteria (≥80%). There was no loss to follow-up, and no non-use, meeting adherence criteria (both ≤10%). Further, 48.0% (95% CI 33.7−62.6; n = 24) of households appropriately used and 56.0% (41.3−70.0; n = 28) cleaned the HPS over four weeks, partly meeting adherence criteria (≥50%). For acceptability, 41.0% (31.3−51.3; n = 41) of infants were in the HPS during random visits, failing criteria (≥50%). Further, the proportion of HPS use decreased during some activities, failing criteria (no decrease in use). A modified Barrier Analysis described good acceptability and multiple secondary benefits, including on women’s time burden and infant injury prevention. Interpretation Despite failing some a priori criteria, the trial demonstrated mixed adherence and good acceptability among intervention households. A definitive trial to determine efficacy is warranted if recommended adjustments are made. Funding People In Need; Czech Development Agency. Trial registration RIDIE-ID-5de0b6938afb8. This research tested a new way to protect infants and young children from infections that are caused by pathogens in human and animal faeces. It tested the feasibility of using a household playspace to reduce infection by creating a hygienic environment for children to play-in in rural Ethiopia. The results show that the household playspace was well accepted, used regularly and cleaned well by participants in the study. The study also suggests a potential positive impact in reducing diarrhoea. Based on these results, we suggest that a larger scale trial be conducted to conclusively assess whether a household playspace can protect young children and infants from infection in rural Ethiopia or similar contexts.
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Affiliation(s)
- Sophie Budge
- Cranfield Water Science Institute, Cranfield University, Cranfield, United Kingdom
| | - Paul Hutchings
- Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Alison Parker
- Cranfield Water Science Institute, Cranfield University, Cranfield, United Kingdom
| | - Sean Tyrrel
- Cranfield Water Science Institute, Cranfield University, Cranfield, United Kingdom
| | - Sam Norton
- Psychology Department, Institute of Psychiatry Psychology & Neuroscience, King’s College London, London, United Kingdom
| | | | | | | | - Mathewos Moges
- Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Siraj Hussen
- Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Hunachew Beyene
- Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
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128
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Vila-Guilera J, Parikh P, Chaturvedi H, Ciric L, Lakhanpaul M. Towards transformative WASH: an integrated case study exploring environmental, sociocultural, economic and institutional risk factors contributing to infant enteric infections in rural tribal India. BMC Public Health 2021; 21:1331. [PMID: 34229646 PMCID: PMC8262041 DOI: 10.1186/s12889-021-11353-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/22/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite clear linkages between poor Water, Sanitation, Hygiene (WASH) and enteric disease, the design of effective WASH interventions that reduce child enteric infections and stunting rates has proved challenging. WASH factors as currently defined do not capture the overall exposure factors to faecal pathogens through the numerous infection transmission pathways. Understanding the multiple and multifaceted factors contributing to enteric infections and their interconnectedness is key to inform future interventions. This study aimed to perform an in-depth holistic exploration of the environmental, socio-cultural, economic and institutional context surrounding infants to develop an integrated understanding of enteric infection drivers in rural tribal Banswara, in Rajasthan State, India. METHODS This study relied on the triangulation of mixed-methods to capture critical influences contributing to infant enteric infection transmission. We conducted structured observations and exploratory qualitative research across 9 rural tribal villages, including transect walks, household observations, interviews with frontline health workers and group discussions with mothers. The emergent social themes and identified factors were mapped based on the scale of agency (individual, family or community-level factor) and on their nature (environmental, socio-cultural, economic and institutional factors). RESULTS Infants aged 5 to 24 months were seen to have constant exposures to dirt via mouthing of soil, soiled hands, soiled objects and food. Rudimentary household environments with dirt floors and domestic animals lacked a hygiene-enabling environment that hindered hygienic behaviour adoption. Several unsafe behaviours failing to interrupt infants' exposures to pathogens were captured, but caregivers reported a lack of self-efficacy skills to separate children from faecal exposures due to the rural farming environments where they lived. Conceptual mapping helped understand how wider-level societal factors such as socio-economic limitations, caste inequalities, and political corruption may have trickle-down effects on the caregivers' motivation and perceived self-efficacy for improving hygiene levels around children, highlighting the influence of interconnected broader factors. CONCLUSIONS Conceptual mapping proved useful to develop an integrated understanding of the interlinked factors across socio-ecological levels and domains, highlighting the role of wider sociocultural, economic and institutional factors contributing to infant's enteric infection risks. Future WASH interventions are likely to require similar integrated approaches that account for the complex factors at all levels.
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Affiliation(s)
- Julia Vila-Guilera
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK.
| | - Priti Parikh
- Engineering for International Development Centre, The Bartlett, UCL Faculty of the Built Environment, London, WC1H 0QB, UK
| | - Hemant Chaturvedi
- Aceso Global Health Consultants Ltd., Chanakya Place 1, New Delhi, 110059, India
| | - Lena Ciric
- Healthy Infrastructure Research Group, UCL Department of Civil, Environmental and Geomatic Engineering, London, WC1E 6BT, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Whittington Health NHS Trust, London, N19 5NF, UK
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129
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Meyer DD, Hill C, McCain K, Smith JA, Bessong PO, Rogawski McQuade ET, Wright NC. Embedding Usage Sensors in Point-of-Use Water Treatment Devices: Sensor Design and Application in Limpopo, South Africa. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:8955-8964. [PMID: 34133882 PMCID: PMC9207768 DOI: 10.1021/acs.est.0c08683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Health benefits from point-of-use (POU) water treatment devices come only with consistent use. Embedded sensors can measure the consistency of POU-device use and can provide insights about improving it. We demonstrate both potentials with data from SmartSpouts: accelerometer-based sensors embedded in spigot handles that record the duration and timing of use. In the laboratory, most sensor readings correlated well (>0.98) with manually timed water withdrawals. In the field, SmartSpouts measured >60,000 water withdrawals across 232 households in Limpopo, South Africa. Sensors proved critical to understanding consistent use; surveys overestimated it by 53 percentage points. Sensor data showed when households use POU devices (evening peaks and delayed weekend routines) and user preferences (safe storage over filters). We demonstrate analytically and with data that (i) consistent use (e.g., 7 continuous days) is extremely sensitive to single-day use prevalence and (ii) use prevalence affects the performance of contact-time-based POU devices, exemplified with silver tablets. Deployed SmartSpouts had limitations, including memory overflows and confounding device relocation with water withdrawal. Nevertheless, SmartSpouts provided useful and objective data on the prevalence of single-day and consistent use. Considerably less expensive than alternatives, SmartSpouts enable an order of magnitude increase in how many POU-device sensors can be deployed.
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Affiliation(s)
- David D Meyer
- Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Courtney Hill
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - Kelly McCain
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - James A Smith
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - Pascal O Bessong
- University of Virginia, Charlottesville, Virginia 22904, United States
- University of Venda, Thohoyandou 0950, Limpopo, South Africa
| | | | - Natasha C Wright
- Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
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130
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Nounkeu CD, Dharod JM. Integrated Approach in Addressing Undernutrition in Developing Countries: A Scoping Review of Integrated Water Access, Sanitation, and Hygiene (WASH) + Nutrition Interventions. Curr Dev Nutr 2021; 5:nzab087. [PMID: 34268466 PMCID: PMC8275452 DOI: 10.1093/cdn/nzab087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
A scoping review of integrated water access, sanitation, and hygiene (WASH) plus nutrition interventions was conducted mainly to describe different components of intervention and examine their effectiveness in improving nutritional outcomes among children. Of the 8 small- to large-scale interventions, 6 were conducted in sub-Saharan Africa and the remaining 2 in South Asia. All the interventions were done in rural settings; the majority involved sanitation and hygiene deliverables along with the nutrition strategies, such as distribution of nutrition supplements. In assessing effectiveness, no significant improvements were seen in growth indicators; reduction in diarrheal rate among children was also not universal across interventions. Further strengthening of WASH, especially an improvement in "W", or water access, is warranted to ensure uptake of sanitation and hygiene behaviors and prevent the fecal-oral route among children. Improved water access will also enhance the effectiveness of nutrition initiatives, such as promoting vegetable gardening and utilization of child nutrient supplements.
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Affiliation(s)
| | - Jigna M Dharod
- Department of Nutrition, University of North Carolina at Greensboro, Greensboro, NC, USA
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131
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Heng S, Kang H, Small DS, Fogarty CB. Increasing power for observational studies of aberrant response: An adaptive approach. J R Stat Soc Series B Stat Methodol 2021. [DOI: 10.1111/rssb.12424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Siyu Heng
- University of Pennsylvania Philadelphia PA USA
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132
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Hurley KM, Phuka J, Kang Y, Ruel-Bergeron J, Buckland AJ, Mitra M, Wu L, Klemm RDW, West KP, Christian P. A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi. Am J Clin Nutr 2021; 114:248-256. [PMID: 33742208 DOI: 10.1093/ajcn/nqab010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.
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Affiliation(s)
- Kristen M Hurley
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John Phuka
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Yunhee Kang
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Julie Ruel-Bergeron
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Audrey J Buckland
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maithilee Mitra
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lee Wu
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rolf D W Klemm
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nutrition, Helen Keller International, New York, NY, USA
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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133
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Quattrochi JP, Coville A, Mvukiyehe E, Dohou CJ, Esu F, Cohen B, Bokasola YL, Croke K. Effects of a community-driven water, sanitation and hygiene intervention on water and sanitation infrastructure, access, behaviour, and governance: a cluster-randomised controlled trial in rural Democratic Republic of Congo. BMJ Glob Health 2021; 6:bmjgh-2021-005030. [PMID: 34001519 PMCID: PMC8130731 DOI: 10.1136/bmjgh-2021-005030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/27/2021] [Accepted: 04/16/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Inadequate water and sanitation is a central challenge in global health. Since 2008, the Democratic Republic of Congo government has implemented a national programme, Healthy Villages and Schools (Villages et Ecoles Assainis (VEA), with support from UNICEF, financed by UK's Foreign, Commonwealth and Development Office. METHODS A cluster-level randomised controlled trial of VEA was implemented throughout 2019 across 332 rural villages, grouped into 50 treatment and 71 control clusters. Primary outcomes included time spent collecting water; quantity of water collected; prevalence of improved primary source of drinking water; and prevalence of improved primary defecation site. Secondary outcomes included child health, water governance, water satisfaction, handwashing practices, sanitation practices, financial cost of water, school attendance and water storage practices. All outcomes were self-reported. The primary analysis was on an intention-to-treat basis, using linear models. Outcomes were measured October-December 2019, median 5 months post-intervention. RESULTS The programme increased access to improved water sources by 33 percentage points (pp) (95% CI 22 to 45), to improved sanitation facilities by 26 pp (95% CI 14 to 37), and improved water governance by 1.3 SDs (95% CI 1.1 to 1.5), water satisfaction by 0.6 SD (95% CI 0.4 to 0.9), handwashing practices by 0.5 SD (95% CI 0.3 to 0.7) and sanitation practices by 0.3 SD (95% CI 0.1 to 0.4). There was no significant difference in financial cost of water, school attendance, child health or water storage practices. CONCLUSION VEA produced large increases in access to and satisfaction with water and sanitation services, in self-reported hygiene and sanitation behaviour, and in measures of water governance. TRIAL REGISTRATION NUMBER AEARCTR-0004648; American Economic Association RCT registry.
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Affiliation(s)
| | - Aidan Coville
- Development Impact Evaluation Department, World Bank Group, Washington, District of Columbia, USA
| | - Eric Mvukiyehe
- Development Impact Evaluation Department, World Bank Group, Washington, District of Columbia, USA
| | - Caleb Jeremie Dohou
- Development Impact Evaluation Department, The World Bank Group, Kinshasa, Democratic Republic of Congo
| | - Federica Esu
- Research, Assessment, and Monitoring Department, World Food Programme, Rome, Italy
| | - Byron Cohen
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Yannick Lokaya Bokasola
- Development Impact Evaluation Department, The World Bank Group, Kinshasa, Democratic Republic of Congo
| | - Kevin Croke
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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134
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Freeman MC, Ellis AS, Ogutu EA, Caruso BA, Linabarger M, Micek K, Muga R, Girard AW, Wodnik BK, Jacob Arriola K. Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-002806. [PMID: 33234528 PMCID: PMC7689101 DOI: 10.1136/bmjgh-2020-002806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/06/2020] [Accepted: 08/21/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health. METHODS We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods. RESULTS Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6-24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline. CONCLUSION Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.
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Affiliation(s)
- Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA .,Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Anna S Ellis
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Emily Awino Ogutu
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Molly Linabarger
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Katie Micek
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Richard Muga
- Faculty of Health Sciences, Uzima University, Kisumu, Kenya
| | - Amy Webb Girard
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Breanna K Wodnik
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Kimberly Jacob Arriola
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
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135
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Rogawski McQuade ET, Benjamin-Chung J, Westreich D, Arnold BF. Population intervention effects in observational studies to emulate target trial results: reconciling the effects of improved sanitation on child growth. Int J Epidemiol 2021; 51:279-290. [PMID: 34151953 DOI: 10.1093/ije/dyab070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improved sanitation has been associated with improved child growth in observational studies, but multiple randomized trials that delivered improved sanitation found no effect on child growth. We assessed to what extent differences in the effect estimated in the two study designs (the effect of treatment in observational studies and the effect of treatment assignment in trials) could explain the contradictory results. METHODS We used parametric g-computation in five prospective studies (n = 21 524) and 59 cross-sectional Demographic and Health Surveys (DHS; n = 158 439). We compared the average treatment effect (ATE) for improved sanitation on mean length-for-age z-score (LAZ) among children aged <2 years to population intervention effects (PIEs), which are the observational analogue of the effect estimated in trials in which some participants are already exposed. RESULTS The ATE was >0.15 z-scores, a clinically meaningful difference, in most prospective studies but in <20% of DHS surveys. The PIE was always smaller than the ATE, and the magnitude of difference depended on the baseline prevalence of the improved sanitation. Interventions with suboptimal coverage and interventions delivered in populations with higher mean LAZ had a smaller effect on population-level LAZ. CONCLUSIONS Estimates of PIEs corresponding to anticipated trial results were often smaller than clinically meaningful effects. Incongruence between observational associations and null trial results may in part be explained by expected differences between the effects estimated. Using observational ATEs to set expectations for trials may overestimate the impact that sanitation interventions can achieve. PIEs predict realistic effects and should be more routinely estimated.
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Affiliation(s)
- Elizabeth T Rogawski McQuade
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology & Biostatistics, University of California, Berkeley, CA, USA
| | - Daniel Westreich
- Division of Epidemiology, University of North Carolina-Chapel Hill, NC, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
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Sahiledengle B, Agho K. Determinants of Childhood Diarrhea in Households with Improved Water, Sanitation, and Hygiene (WASH) in Ethiopia: Evidence from a Repeated Cross-Sectional Study. ENVIRONMENTAL HEALTH INSIGHTS 2021; 15:11786302211025180. [PMID: 34220201 PMCID: PMC8221697 DOI: 10.1177/11786302211025180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/25/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Determinants of childhood diarrhea in households with improved WASH (ie, households with improved drinking water sources, improved sanitation facilities, and those who practiced safe child stool disposal) are limited. This study aimed to identify the determinants of diarrhea among under-five children exclusively in households with improved Water, Sanitation, and Hygiene (WASH). METHODS A repeated cross-sectional study design was followed, and data from the Demographic and Health Survey (DHS) conducted between 2005 and 2016 in Ethiopia was used. A total of 1,975 child-mother pairs (257 children with diarrhea and 1718 children without diarrhea) in households with improved WASH were included in this study. Hierarchical conditional logistic regression models were used. Adjusted odds ratios (AOR) with corresponding 95% confidence intervals (CI) were estimated to determine the strength of association. RESULTS Children aged 13 to 24 months (Adjusted Odds Ratio [AOR] = 2.70, 95%CI: 1.69-4.32), children who did not receive the measles vaccine (AOR = 2.33, 95%CI: 1.60-3.39), and those residing in the agrarian region (AOR = 1.66, 95%CI: 1.10-2.49) were significantly more likely to develop diarrheal morbidity. The size of the child at birth was also found to be significantly associated with diarrheal morbidity. CONCLUSION In this study, child factors (age of the child, vaccinated for measles, and the size of a child at birth), and household-related factors (contextual region) had a significant effect on the risk of childhood diarrheal morbidity in households with improved WASH in Ethiopia.
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Affiliation(s)
- Biniyam Sahiledengle
- Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Kingsley Agho
- School of Health Sciences, Western Sydney University, Sydney, NSW, Australia
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137
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Contreras JD, Islam M, Mertens A, Pickering AJ, Kwong LH, Arnold BF, Benjamin-Chung J, Hubbard AE, Alam M, Sen D, Islam S, Rahman M, Unicomb L, Luby SP, Colford JM, Ercumen A. Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:8169-8179. [PMID: 34086447 PMCID: PMC8213058 DOI: 10.1021/acs.est.1c01114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 05/06/2023]
Abstract
Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1-3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.
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Affiliation(s)
- Jesse D. Contreras
- Department
of Forestry and Environmental Resources, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Mahfuza Islam
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Andrew Mertens
- Division
of Epidemiology and Biostatistics, School
of Public Health, University of California, Berkeley, California 94720, United States
| | - Amy J. Pickering
- Department
of Civil and Environmental Engineering, University of California, Berkeley, California 94720, United States
| | - Laura H. Kwong
- Woods
Institute for the Environment, Stanford
University, Stanford, California 94305, United States
| | - Benjamin F. Arnold
- Francis I.
Proctor Foundation, University of California, San Francisco, California 94143, United States
| | - Jade Benjamin-Chung
- Division
of Epidemiology and Biostatistics, School
of Public Health, University of California, Berkeley, California 94720, United States
| | - Alan E. Hubbard
- Division
of Epidemiology and Biostatistics, School
of Public Health, University of California, Berkeley, California 94720, United States
| | - Mahfuja Alam
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Debashis Sen
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Sharmin Islam
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Mahbubur Rahman
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Leanne Unicomb
- Environmental
Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Stephen P. Luby
- Woods
Institute for the Environment, Stanford
University, Stanford, California 94305, United States
| | - John M. Colford
- Division
of Epidemiology and Biostatistics, School
of Public Health, University of California, Berkeley, California 94720, United States
| | - Ayse Ercumen
- Department
of Forestry and Environmental Resources, North Carolina State University, Raleigh, North Carolina 27695, United States
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Thompson AJ, Bourke CD, Robertson RC, Shivakumar N, Edwards CA, Preston T, Holmes E, Kelly P, Frost G, Morrison DJ. Understanding the role of the gut in undernutrition: what can technology tell us? Gut 2021; 70:gutjnl-2020-323609. [PMID: 34103403 PMCID: PMC8292602 DOI: 10.1136/gutjnl-2020-323609] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/04/2021] [Indexed: 12/22/2022]
Abstract
Gut function remains largely underinvestigated in undernutrition, despite its critical role in essential nutrient digestion, absorption and assimilation. In areas of high enteropathogen burden, alterations in gut barrier function and subsequent inflammatory effects are observable but remain poorly characterised. Environmental enteropathy (EE)-a condition that affects both gut morphology and function and is characterised by blunted villi, inflammation and increased permeability-is thought to play a role in impaired linear growth (stunting) and severe acute malnutrition. However, the lack of tools to quantitatively characterise gut functional capacity has hampered both our understanding of gut pathogenesis in undernutrition and evaluation of gut-targeted therapies to accelerate nutritional recovery. Here we survey the technology landscape for potential solutions to improve assessment of gut function, focussing on devices that could be deployed at point-of-care in low-income and middle-income countries (LMICs). We assess the potential for technological innovation to assess gut morphology, function, barrier integrity and immune response in undernutrition, and highlight the approaches that are currently most suitable for deployment and development. This article focuses on EE and undernutrition in LMICs, but many of these technologies may also become useful in monitoring of other gut pathologies.
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Affiliation(s)
- Alex J Thompson
- Hamlyn Centre for Robotic Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Claire D Bourke
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Ruairi C Robertson
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Nirupama Shivakumar
- Division of Nutrition, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | - Tom Preston
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
| | - Elaine Holmes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Gary Frost
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Douglas J Morrison
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
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Koyratty N, Jones AD, Schuster R, Kordas K, Li CS, Mbuya MNN, Boateng GO, Ntozini R, Chasekwa B, Humphrey JH, Smith LE. Food Insecurity and Water Insecurity in Rural Zimbabwe: Development of Multidimensional Household Measures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6020. [PMID: 34205143 PMCID: PMC8199942 DOI: 10.3390/ijerph18116020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/26/2022]
Abstract
Background: With millions of people experiencing malnutrition and inadequate water access, FI and WI remain topics of vital importance to global health. Existing unidimensional FI and WI metrics do not all capture similar multidimensional aspects, thus restricting our ability to assess and address food- and water-related issues. Methods: Using the Sanitation, Hygiene and Infant Nutrition Efficacy (SHINE) trial data, our study conceptualizes household FI (N = 3551) and WI (N = 3311) separately in a way that captures their key dimensions. We developed measures of FI and WI for rural Zimbabwean households based on multiple correspondence analysis (MCA) for categorical data. Results: Three FI dimensions were retained: 'poor food access', 'household shocks' and 'low food quality and availability', as were three WI dimensions: 'poor water access', 'poor water quality', and 'low water reliability'. Internal validity of the multidimensional models was assessed using confirmatory factor analysis (CFA) with test samples at baseline and 18 months. The dimension scores were associated with a group of exogenous variables (SES, HIV-status, season, depression, perceived health, food aid, water collection), additionally indicating predictive, convergent and discriminant validities. Conclusions: FI and WI dimensions are sufficiently distinct to be characterized via separate indicators. These indicators are critical for identifying specific problematic insecurity aspects and for finding new targets to improve health and nutrition interventions.
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Affiliation(s)
- Nadia Koyratty
- Department of Epidemiology and Environmental Health, The State University of New York, University at Buffalo, Buffalo, NY 14214, USA; (N.K.); (K.K.)
| | - Andrew D. Jones
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Roseanne Schuster
- Center for Global Health, School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85281, USA;
| | - Katarzyna Kordas
- Department of Epidemiology and Environmental Health, The State University of New York, University at Buffalo, Buffalo, NY 14214, USA; (N.K.); (K.K.)
| | - Chin-Shang Li
- School of Nursing, The State University of New York, University at Buffalo, Buffalo, NY 14214, USA;
| | | | - Godfred O. Boateng
- Department of Kinesiology, College of Nursing and Health Innovations, The University of Texas at Arlington, Arlington, TX 76019, USA;
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; (R.N.); (B.C.); (J.H.H.)
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; (R.N.); (B.C.); (J.H.H.)
| | - Jean H. Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; (R.N.); (B.C.); (J.H.H.)
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Laura E. Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; (R.N.); (B.C.); (J.H.H.)
- Department of Population Medicine and Diagnostics, Cornell University, Ithaca, NY 14853, USA
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Haque SS, Freeman MC. The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:65002. [PMID: 34132602 PMCID: PMC8207965 DOI: 10.1289/ehp7762] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Delivery of high quality, at-scale, and sustained services is a major challenge in the water, sanitation, and hygiene (WASH) sector, made more challenging by a dearth of evidence-based models for adaption across contexts in low- and middle-income countries. OBJECTIVE We aim to describe the value of implementation science (IS) for the WASH sector and provide recommendations for its application. METHODS We review concepts from the growing field of IS-defined as the "scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services"-and we translate their relevance to WASH research, learning, and delivery. DISCUSSION IS provides a suite of methods and theories to systematically develop, evaluate, and scale evidence-based interventions. Though IS thinking has been applied most notably in health services delivery in high-income countries, there have been applications in low-income settings in fields such as HIV/AIDS and nutrition. Expanding the application of IS to environmental health, specifically WASH interventions, would respond to the complexity of sustainable service delivery. WASH researchers may want to consider applying IS guidelines to their work, including adapting pragmatic research models, using established IS frameworks, and cocreating knowledge with local stakeholders. https://doi.org/10.1289/EHP7762.
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Affiliation(s)
- Sabrina S. Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Zavala E, King SE, Sawadogo-Lewis T, Roberton T. Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework. MATERNAL AND CHILD NUTRITION 2021; 17:e13202. [PMID: 33988303 PMCID: PMC8189228 DOI: 10.1111/mcn.13202] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 12/25/2022]
Abstract
In low‐ and middle‐income countries (LMICs), access to water, sanitation and hygiene (WASH) is associated with nutritional status including stunting, which affects 144 million children under 5 globally. Despite the consistent epidemiological association between WASH indicators and nutritional status, the provision of WASH interventions alone has not been found to improve child growth in recent randomized control trials. We conducted a literature review to develop a new conceptual framework that highlights what is known about the WASH to nutrition pathways, the limitations of certain interventions and how future WASH could be leveraged to benefit nutritional status in populations. This new conceptual framework will provide policy makers, program implementors and researchers with a visual tool to bring into perspective multiple levels of WASH and how it may effectively influence nutrition while identifying existing gaps in implementation and research.
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Affiliation(s)
- Eleonor Zavala
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shannon E King
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Talata Sawadogo-Lewis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Timothy Roberton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Lappan R, Henry R, Chown SL, Luby SP, Higginson EE, Bata L, Jirapanjawat T, Schang C, Openshaw JJ, O'Toole J, Lin A, Tela A, Turagabeci A, Wong THF, French MA, Brown RR, Leder K, Greening C, McCarthy D. Monitoring of diverse enteric pathogens across environmental and host reservoirs with TaqMan array cards and standard qPCR: a methodological comparison study. Lancet Planet Health 2021; 5:e297-e308. [PMID: 33964239 PMCID: PMC8116308 DOI: 10.1016/s2542-5196(21)00051-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 05/25/2023]
Abstract
BACKGROUND Multiple bacteria, viruses, protists, and helminths cause enteric infections that greatly impact human health and wellbeing. These enteropathogens are transmited via several pathways through human, animal, and environmental reservoirs. Individual qPCR assays have been extensively used to detect enteropathogens within these types of samples, whereas the TaqMan array card (TAC), which allows simultaneous detection of multiple enteropathogens, has only previously been validated in human clinical samples. METHODS In this methodological comparison study, we compared the performance of a custom 48-singleplex TAC relative to standard qPCR. We established the sensitivity and specificity of each method for the detection of eight enteric targets, by using spiked samples with varying levels of PCR inhibition. We then tested the prevalence and abundance of pathogens in wastewater from Melbourne (Australia), and human, animal, and environmental samples from informal settlements in Suva, Fiji using both TAC and qPCR. FINDINGS Both methods exhibited similarly h specificity (TAC 100%, qPCR 94%), sensitivity (TAC 92%, qPCR 100%), and quantitation accuracy (TAC 91%, qPCR 99%) in non-inhibited sample matrices with spiked gene fragments. PCR inhibitors substantially affected detection via TAC, though this issue was alleviated by ten-fold sample dilution. Among samples from informal settlements, the two techniques performed similarly for detection (89% agreement) and quantitation (R2 0·82) for the eight enteropathogen targets. The TAC additionally included 38 other enteric targets, enabling detection of diverse faecal pathogens and extensive environmental contamination that would be prohibitively labour intensive to assay by standard qPCR. INTERPRETATION The two techniques produced similar results across diverse sample types, with qPCR prioritising greater sensitivity and quantitation accuracy, and TAC trading small reductions in these for a cost-effective larger enteropathogen panel enabling a greater number of enteric pathogens to be analysed concurrently, which is beneficial given the abundance and variety of enteric pathogens in environments such as urban informal settlements. The ability to monitor multiple enteric pathogens across diverse reservoirs could allow better resolution of pathogen exposure pathways, and the design and monitoring of interventions to reduce pathogen load. FUNDING Wellcome Trust Our Planet, Our Health programme.
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Affiliation(s)
- Rachael Lappan
- Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- School of Biological Sciences, Monash University, Clayton, VIC, Australia
| | - Rebekah Henry
- Department of Civil Engineering, Monash University, Clayton, VIC, Australia
| | - Steven L Chown
- School of Biological Sciences, Monash University, Clayton, VIC, Australia
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Ellen E Higginson
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Lamiya Bata
- Department of Civil Engineering, Monash University, Clayton, VIC, Australia
| | - Thanavit Jirapanjawat
- Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- School of Biological Sciences, Monash University, Clayton, VIC, Australia
| | - Christelle Schang
- Department of Civil Engineering, Monash University, Clayton, VIC, Australia
| | - John J Openshaw
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Joanne O'Toole
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, CA, USA
| | - Autiko Tela
- School of Public Health, Fiji National University, Suva, Fiji
| | | | - Tony H F Wong
- Water Sensitive Cities Institute, Monash University, Clayton, VIC, Australia
| | - Matthew A French
- Monash Sustainable Development Institute, Monash University, Clayton, VIC, Australia
| | - Rebekah R Brown
- Monash Sustainable Development Institute, Monash University, Clayton, VIC, Australia
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Chris Greening
- Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- School of Biological Sciences, Monash University, Clayton, VIC, Australia
| | - David McCarthy
- Department of Civil Engineering, Monash University, Clayton, VIC, Australia
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Workman CL, Cairns MR, de los Reyes FL, Verbyla ME. Global Water, Sanitation, and Hygiene Approaches: Anthropological Contributions and Future Directions for Engineering. ENVIRONMENTAL ENGINEERING SCIENCE 2021; 38:402-417. [PMID: 34079211 PMCID: PMC8165478 DOI: 10.1089/ees.2020.0321] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/20/2021] [Indexed: 06/12/2023]
Abstract
Anthropologists contribute key insights toward a comprehensive understanding of water, sanitation, and hygiene (WASH) as a multidimensional, multiscalar, and culturally embedded phenomenon. Yet, these insights have yet to be sufficiently operationalized and implemented in WASH development and wider WASH access-related paradigms. Ensuring WASH security requires a comprehensive approach to identifying both human health risk and environmental impact of WASH-related programs and strategies. It requires an understanding of how sanitation is integrated into households and communities and how individuals within particular cultural contexts practice sanitation and hygiene. This work facilitates that goal by outlining the major contributions of anthropology and allied social sciences to WASH, as well as outlining key considerations for future work and collaboration. We identify six major themes that, if applied in future engineering approaches, will more equitably integrate stakeholders and multiple vantage points in the successful implementation of WASH projects for marginalized and diverse groups. These include a critical understanding of previous approaches, culturally aware interventions, capacity building that considers (un)intended impact, co-created technology, collaboration between fields such as anthropology and engineering, and challenge-ready initiatives that respond to historic and emergent social and environmental inequity.
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Affiliation(s)
- Cassandra L. Workman
- Department of Anthropology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Maryann R. Cairns
- Department of Anthropology, Southern Methodist University, Dallas, Texas, USA
| | - Francis L. de los Reyes
- Department of Civil, Construction, and Environmental Engineering, North Carolina State University, Raleigh, North Carolina, USA
| | - Matthew E. Verbyla
- Department of Civil and Environmental Engineering, San Diego State University, San Diego, California, USA
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Cameron L, Santos P, Thomas M, Albert J. Sanitation, financial incentives and health spillovers: A cluster randomised trial. JOURNAL OF HEALTH ECONOMICS 2021; 77:102456. [PMID: 33857858 DOI: 10.1016/j.jhealeco.2021.102456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 06/12/2023]
Abstract
Poor sanitation and its consequent negative health outcomes continue to plague the developing world. Drawing on the finding that financial subsidies have changed behaviour in other health contexts, we conducted a clustered randomised trial in 160 villages in Lao PDR to evaluate the effectiveness of combining financial incentives with Community-Led Total Sanitation (CLTS), a widely-conducted behaviour change program. Villages were randomly allocated to four groups, all of which received CLTS but differed in the type of subsidy offered (none, household, village or both). Using data from a random sample of households with young children and village administrative data, we show that household incentives increased sanitation take-up among the poor, whereas a village incentive increased take-up primarily among the non-poor. Improved sanitation produced positive health spillovers - a 10 percentage point increase in village sanitation coverage decreased the probability of childhood stunting by 3 percentage points.
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Affiliation(s)
- Lisa Cameron
- Melbourne Institute: Applied Economic and Social Research, Level 5, FBE Building, 111 Barry St, University of Melbourne, 3010, Vic., Australia.
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Peletz R, Delaire C, Kones J, MacLeod C, Samuel E, Easthope-Frazer A, Khush R. Will Households Invest in Safe Sanitation? Results from an Experimental Demand Trial in Nakuru, Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094462. [PMID: 33922311 PMCID: PMC8122837 DOI: 10.3390/ijerph18094462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 11/16/2022]
Abstract
Unsafe sanitation is an increasing public health concern for rapidly expanding cities in low-income countries. Understanding household demand for improved sanitation infrastructure is critical for planning effective sanitation investments. In this study, we compared the stated and revealed willingness to pay (WTP) for high-quality, pour-flush latrines among households in low-income areas in the city of Nakuru, Kenya. We found that stated WTP for high-quality, pour-flush latrines was much lower than market prices: less than 5% of households were willing to pay the full costs, which we estimated between 87,100–82,900 Kenyan Shillings (KES), or 871–829 USD. In addition, we found large discrepancies between stated and revealed WTP. For example, 90% of households stated that they would be willing to pay a discounted amount of 10,000 KES (100 USD) for a high-quality, pour-flush latrine, but only 10% of households redeemed vouchers at this price point (paid via six installment payments). Households reported that financial constraints (i.e., lack of cash, other spending priorities) were the main barriers to voucher redemption, even at highly discounted prices. Our results emphasize the importance of financial interventions that address the sizable gaps between the costs of sanitation products and customer demand among low-income populations.
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Affiliation(s)
- Rachel Peletz
- The Aquaya Institute, P.O. Box 1603, San Anselmo, CA 94979, USA; (C.D.); (A.E.-F.); (R.K.)
- Correspondence:
| | - Caroline Delaire
- The Aquaya Institute, P.O. Box 1603, San Anselmo, CA 94979, USA; (C.D.); (A.E.-F.); (R.K.)
| | - Joan Kones
- The Aquaya Institute, P.O. Box 21862-00505, Nairobi 00100, Kenya; (J.K.); (C.M.); (E.S.)
| | - Clara MacLeod
- The Aquaya Institute, P.O. Box 21862-00505, Nairobi 00100, Kenya; (J.K.); (C.M.); (E.S.)
| | - Edinah Samuel
- The Aquaya Institute, P.O. Box 21862-00505, Nairobi 00100, Kenya; (J.K.); (C.M.); (E.S.)
| | - Alicea Easthope-Frazer
- The Aquaya Institute, P.O. Box 1603, San Anselmo, CA 94979, USA; (C.D.); (A.E.-F.); (R.K.)
| | - Ranjiv Khush
- The Aquaya Institute, P.O. Box 1603, San Anselmo, CA 94979, USA; (C.D.); (A.E.-F.); (R.K.)
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Byrne DM, Hamilton KA, Houser SA, Mubasira M, Katende D, Lohman HAC, Trimmer JT, Banadda N, Zerai A, Guest JS. Navigating Data Uncertainty and Modeling Assumptions in Quantitative Microbial Risk Assessment in an Informal Settlement in Kampala, Uganda. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:5463-5474. [PMID: 33750111 DOI: 10.1021/acs.est.0c05693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Decision-makers in developing communities often lack credible data to inform decisions related to water, sanitation, and hygiene. Quantitative microbial risk assessment (QMRA), which quantifies pathogen-related health risks across exposure routes, can be informative; however, the utility of QMRA for decision-making is often undermined by data gaps. This work integrates QMRA, uncertainty and sensitivity analyses, and household surveys in Bwaise, Kampala (Uganda) to characterize the implications of censored data management, identify sources of uncertainty, and incorporate risk perceptions to improve the suitability of QMRA for informal settlements or similar settings. In Bwaise, drinking water, hand rinse, and soil samples were collected from 45 households and supplemented with data from 844 surveys. Quantified pathogen (adenovirus, Campylobacter jejuni, and Shigella spp./EIEC) concentrations were used with QMRA to model infection risks from exposure through drinking water, hand-to-mouth contact, and soil ingestion. Health risks were most sensitive to pathogen data, hand-to-mouth contact frequency, and dose-response models (particularly C. jejuni). When managing censored data, results from upper limits of detection, half of limits of detection, and uniform distributions returned similar results, which deviated from lower limits of detection and maximum likelihood estimation imputation approaches. Finally, risk perceptions (e.g., it is unsafe to drink directly from a water source) were identified to inform risk management.
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Affiliation(s)
- Diana M Byrne
- Department of Civil and Environmental Engineering, University of Illinois at Urbana-Champaign, 205 North Mathews Avenue, 3221 Newmark Civil Engineering Laboratory, Urbana, Illinois 61801, United States
| | - Kerry A Hamilton
- The School with Sustainable Engineering and the Built Environment and The Biodesign Institute Center for Environmental Health Engineering, Arizona State University, Tempe, Arizona 85287, United States
| | - Stephanie A Houser
- Department of Civil and Environmental Engineering, University of Illinois at Urbana-Champaign, 205 North Mathews Avenue, 3221 Newmark Civil Engineering Laboratory, Urbana, Illinois 61801, United States
| | - Muwonge Mubasira
- Community Integrated Development Initiatives, P.O. Box 764, Kampala, Uganda
| | - David Katende
- Community Integrated Development Initiatives, P.O. Box 764, Kampala, Uganda
| | - Hannah A C Lohman
- Department of Civil and Environmental Engineering, University of Illinois at Urbana-Champaign, 205 North Mathews Avenue, 3221 Newmark Civil Engineering Laboratory, Urbana, Illinois 61801, United States
| | - John T Trimmer
- Department of Civil and Environmental Engineering, University of Illinois at Urbana-Champaign, 205 North Mathews Avenue, 3221 Newmark Civil Engineering Laboratory, Urbana, Illinois 61801, United States
| | - Noble Banadda
- Department of Agricultural & Biosystems Engineering, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Assata Zerai
- Department of Sociology, University of New Mexico, Albuquerque, New Mexico 87131, United States
| | - Jeremy S Guest
- Department of Civil and Environmental Engineering, University of Illinois at Urbana-Champaign, 205 North Mathews Avenue, 3221 Newmark Civil Engineering Laboratory, Urbana, Illinois 61801, United States
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147
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Heidkamp RA, Piwoz E, Gillespie S, Keats EC, D'Alimonte MR, Menon P, Das JK, Flory A, Clift JW, Ruel MT, Vosti S, Akuoku JK, Bhutta ZA. Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action. Lancet 2021; 397:1400-1418. [PMID: 33691095 DOI: 10.1016/s0140-6736(21)00568-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/28/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
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Affiliation(s)
| | - Ellen Piwoz
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Stuart Gillespie
- International Food Policy Research Institute, Washington, DC, USA
| | - Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Purnima Menon
- International Food Policy Research Institute, Delhi, India
| | - Jai K Das
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | | | | | - Marie T Ruel
- International Food Policy Research Institute, Washington, DC, USA
| | - Stephen Vosti
- Department of Agricultural and Resource Economics, and Institute for Global Nutrition, University of California, Davis, CA, USA
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan.
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148
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Victora CG, Christian P, Vidaletti LP, Gatica-Domínguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet 2021; 397:1388-1399. [PMID: 33691094 PMCID: PMC7613170 DOI: 10.1016/s0140-6736(21)00394-9] [Citation(s) in RCA: 256] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/20/2020] [Accepted: 09/23/2020] [Indexed: 12/26/2022]
Abstract
13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.
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Affiliation(s)
- Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
| | - Parul Christian
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Luis Paulo Vidaletti
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Robert E Black
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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149
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Knee J, Sumner T, Adriano Z, Anderson C, Bush F, Capone D, Casmo V, Holcomb D, Kolsky P, MacDougall A, Molotkova E, Braga JM, Russo C, Schmidt WP, Stewart J, Zambrana W, Zuin V, Nalá R, Cumming O, Brown J. Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: A controlled before-and-after trial. eLife 2021; 10:e62278. [PMID: 33835026 PMCID: PMC8121544 DOI: 10.7554/elife.62278] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 04/03/2021] [Indexed: 12/12/2022] Open
Abstract
We conducted a controlled before-and-after trial to evaluate the impact of an onsite urban sanitation intervention on the prevalence of enteric infection, soil transmitted helminth re-infection, and diarrhea among children in Maputo, Mozambique. A non-governmental organization replaced existing poor-quality latrines with pour-flush toilets with septic tanks serving household clusters. We enrolled children aged 1-48 months at baseline and measured outcomes before and 12 and 24 months after the intervention, with concurrent measurement among children in a comparable control arm. Despite nearly exclusive use, we found no evidence that intervention affected the prevalence of any measured outcome after 12 or 24 months of exposure. Among children born into study sites after intervention, we observed a reduced prevalence of Trichuris and Shigella infection relative to the same age group at baseline (<2 years old). Protection from birth may be important to reduce exposure to and infection with enteric pathogens in this setting.
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Affiliation(s)
- Jackie Knee
- London School of Hygiene & Tropical Medicine, Faculty of Infectious Tropical Diseases, Disease Control DepartmentLondonUnited Kingdom
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
| | - Trent Sumner
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
| | | | - Claire Anderson
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
| | - Farran Bush
- Georgia Institute of Technology, School of Chemical and Biomolecular EngineeringAtlantaUnited States
| | - Drew Capone
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of EpidemiologyChapel HillUnited States
| | | | - David Holcomb
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of EpidemiologyChapel HillUnited States
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Environmental Sciences and EngineeringChapel HillUnited States
| | - Pete Kolsky
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of EpidemiologyChapel HillUnited States
| | - Amy MacDougall
- London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, Department of Medical StatisticsLondonUnited Kingdom
| | - Evgeniya Molotkova
- Georgia Institute of Technology, School of Biological SciencesAtlantaUnited States
| | | | - Celina Russo
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
| | - Wolf Peter Schmidt
- London School of Hygiene & Tropical Medicine, Faculty of Infectious Tropical Diseases, Disease Control DepartmentLondonUnited Kingdom
| | - Jill Stewart
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of EpidemiologyChapel HillUnited States
| | - Winnie Zambrana
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
| | - Valentina Zuin
- Yale-NUS College, Division of Social ScienceSingaporeSingapore
| | | | - Oliver Cumming
- London School of Hygiene & Tropical Medicine, Faculty of Infectious Tropical Diseases, Disease Control DepartmentLondonUnited Kingdom
| | - Joe Brown
- Georgia Institute of Technology, School of Civil and Environmental EngineeringAtlantaUnited States
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of EpidemiologyChapel HillUnited States
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150
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Wu T, Shi H, Niu J, Yin X, Wang X, Shen Y. Distance to water source in early childhood affects growth: a cohort study. Public Health 2021; 193:139-145. [PMID: 33838573 DOI: 10.1016/j.puhe.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Approximately 165 million children aged <5 years are at risk of low height-for-age. This study explored whether water quality and distance to water source affected short- and long-term growth, and the critical time windows of such effects. STUDY DESIGN This study used data from the China Health and Nutrition Survey (CHNS), which was a cohort study performed in 15 Chinese provinces. METHODS Data from the CHNS between 1989 and 2011 were examined. Three cohorts of children who were enrolled at 0-2 years of age in 1989, 1993, and 2000 provided sufficient data for this study. Child height was measured by physicians, and household water supply, including the water quality (safe or unsafe) and distance to the source (in-yard or out-yard), was assessed using a questionnaire when the children were 0-2, 4-6, and 11-13 years of age. Multiple regressions were performed to analyse the associations between water quality and distance to the source at various ages, and height at that age and older ages, with and without adjusting for the household water supply at previous ages. Multiple informant models were created using a generalised estimating equation and these were used to assess whether the exposure coefficients were equal across the three age periods. RESULTS A total of 1192 children were included. Water quality was not significantly associated with height over the three age periods. An out-yard water source at the age of 0-2 years was not associated with child height at that age, but it was inversely associated with child height at ages 4-6 and 11-13 years (β = -1.605, 95% confidence interval [CI]: -2.490 to -0.720, and β = -2.817, 95% CI: -4.411 to -1.224, respectively), after adjusting for sociodemographic and economic covariates and baseline child height. Distance to the water source at age 4-6 and 11-13 years was not significantly associated with height. However, significant differences were observed in the associations between distance to water source across the three age periods and height at age 4-6 and 11-13 years (pint = 0.064 and 0.069, respectively). CONCLUSIONS Distance to the water source in early, but not later, childhood exerted a long-term effect on child height. When the water quality is good, efforts should be made to shorten the distance to the source to improve child health and growth.
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Affiliation(s)
- T Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - H Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - J Niu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - X Yin
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - X Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China; National Health Commission Key Laboratory of Reproductive Health, Beijing, China.
| | - Y Shen
- School of Economics and Resource Management, Beijing Normal University, Beijing, China.
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