title: Association between intensive handwashing promotion and child development in Karachi, Pakistan: a cluster randomized controlled trial.
abstract: OBJECTIVE
  To evaluate associations between handwashing promotion and child growth and development.
  
  
  METHODS
  Cluster randomized controlled trial.
  
  
  METHODS
  Informal settlements in Karachi, Pakistan.
  
  
  METHODS
  A total of 461 children who were enrolled in a trial of household-level handwashing promotion in 2003 and were younger than 8 years at reassessment in 2009.
  
  
  METHODS
  In 2003, neighborhoods were randomized to control (n = 9), handwashing promotion (n = 9), or handwashing promotion and drinking water treatment (n = 10); intervention households received free soap and weekly handwashing promotion for 9 months.
  
  
  METHODS
  Anthropometrics and developmental quotients measured with the Battelle Developmental Inventory II at 5 to 7 years of age.
  
  
  RESULTS
  Overall, 24.9% (95% CI, 20.0%-30.6%) and 22.1% (95% CI, 18.0%-26.8%) of children had z scores that were more than 2 SDs below the expected z scores for height and body mass index for age, respectively; anthropometrics did not differ significantly across study groups. Global developmental quotients averaged 104.4 (95% CI, 101.9-107.0) among intervention children and 98.3 (95% CI, 93.1-103.4) among control children (P = .04). Differences of similar magnitude were measured across adaptive, personal-social, communication, cognitive, and motor domains.
  
  
  CONCLUSIONS
  Although growth was similar across groups, children randomized to the handwashing promotion during their first 30 months of age attained global developmental quotients 0.4 SDs greater than those of control children at 5 to 7 years of age. These gains are comparable to those of at-risk children enrolled in publicly funded preschools in the United States and suggest that handwashing promotion could improve child well-being and societal productivity.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01538953.
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. abowen@cdc.gov
authors.forename: Anna
authors.initials: A
authors.lastname: Bowen
authors.forename: Mubina
authors.initials: M
authors.lastname: Agboatwalla
authors.forename: Stephen
authors.initials: S
authors.lastname: Luby
authors.forename: Timothy
authors.initials: T
authors.lastname: Tobery
authors.forename: Tracy
authors.initials: T
authors.lastname: Ayers
authors.forename: R M
authors.initials: RM
authors.lastname: Hoekstra
mesh_terms: D001827:Body Height; D001835:Body Weight; D002648:Child; D002657:Child Development; D002675:Child, Preschool; D060766:Drinking Water; D005260:Female; D005500:Follow-Up Studies; D006235:Hand Disinfection; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010154:Pakistan; D011581:Psychological Tests; D018508:Water Purification
chemical_list: D060766:Drinking Water