title: Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children.
abstract: BACKGROUND
  Water, sanitation and hygiene (WASH) interventions are frequently implemented to reduce infectious diseases, and may be linked to improved nutrition outcomes in children.
  
  
  OBJECTIVE
  To evaluate the effect of interventions to improve water quality and supply (adequate quantity to maintain hygiene practices), provide adequate sanitation and promote handwashing with soap, on the nutritional status of children under the age of 18 years and to identify current research gaps.
  
  
  METHODS
  We searched 10 English-language (including MEDLINE and CENTRAL) and three Chinese-language databases for published studies in June 2012. We searched grey literature databases, conference proceedings and websites, reviewed reference lists and contacted experts and authors.
  
  
  METHODS
  Randomised (including cluster-randomised), quasi-randomised and non-randomised controlled trials, controlled cohort or cross-sectional studies and historically controlled studies, comparing WASH interventions among children aged under 18 years.
  
  
  METHODS
  Two review authors independently sought and extracted data on childhood anthropometry, biochemical measures of micronutrient status, and adherence, attrition and costs either from published reports or through contact with study investigators. We calculated mean difference (MD) with 95% confidence intervals (CI). We conducted study-level and individual-level meta-analyses to estimate pooled measures of effect for randomised controlled trials only.
  
  
  RESULTS
  Fourteen studies (five cluster-randomised controlled trials and nine non-randomised studies with comparison groups) from 10 low- and middle-income countries including 22,241 children at baseline and nutrition outcome data for 9,469 children provided relevant information. Study duration ranged from 6 to 60 months and all studies included children under five years of age at the time of the intervention. Studies included WASH interventions either singly or in combination. Measures of child anthropometry were collected in all 14 studies, and nine studies reported at least one of the following anthropometric indices: weight-for-height, weight-for-age or height-for-age. None of the included studies were of high methodological quality as none of the studies masked the nature of the intervention from participants.Weight-for-age, weight-for-height and height-for-age z-scores were available for five cluster-randomised controlled trials with a duration of between 9 and 12 months. Meta-analysis including 4,627 children identified no evidence of an effect of WASH interventions on weight-for-age z-score (MD 0.05; 95% CI -0.01 to 0.12). Meta-analysis including 4,622 children identified no evidence of an effect of WASH interventions on weight-for-height z-score (MD 0.02; 95% CI -0.07 to 0.11). Meta-analysis including 4,627 children identified a borderline statistically significant effect of WASH interventions on height-for-age z-score (MD 0.08; 95% CI 0.00 to 0.16). These findings were supported by individual participant data analysis including information on 5,375 to 5,386 children from five cluster-randomised controlled trials.No study reported adverse events. Adherence to study interventions was reported in only two studies (both cluster-randomised controlled trials) and ranged from low (< 35%) to high (> 90%). Study attrition was reported in seven studies and ranged from 4% to 16.5%. Intervention cost was reported in one study in which the total cost of the WASH interventions was USD 15/inhabitant. None of the studies reported differential impacts relevant to equity issues such as gender, socioeconomic status and religion.
  
  
  CONCLUSIONS
  The available evidence from meta-analysis of data from cluster-randomised controlled trials with an intervention period of 9-12 months is suggestive of a small benefit of WASH interventions (specifically solar disinfection of water, provision of soap, and improvement of water quality) on length growth in children under five years of age. The duration of the intervention studies was relatively short and none of the included studies is of high methodological quality. Very few studies provided information on intervention adherence, attrition and costs. There are several ongoing trials in low-income country settings that may provide robust evidence to inform these findings.
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT.
authors.forename: Alan D
authors.initials: AD
authors.lastname: Dangour
authors.forename: Louise
authors.initials: L
authors.lastname: Watson
authors.forename: Oliver
authors.initials: O
authors.lastname: Cumming
authors.forename: Sophie
authors.initials: S
authors.lastname: Boisson
authors.forename: Yan
authors.initials: Y
authors.lastname: Che
authors.forename: Yael
authors.initials: Y
authors.lastname: Velleman
authors.forename: Sue
authors.initials: S
authors.lastname: Cavill
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Allen
authors.forename: Ricardo
authors.initials: R
authors.lastname: Uauy
mesh_terms: D000367:Age Factors; D001827:Body Height; D001835:Body Weight; D002675:Child, Preschool; D003906:Developing Countries; D006235:Hand Disinfection / Q000592:standards*; D006801:Humans; D006920:Hygiene / Q000592:standards*; D007223:Infant; D044342:Malnutrition / Q000517:prevention & control; D009752:Nutritional Status; D016032:Randomized Controlled Trials as Topic; D012499:Sanitation / Q000379:methods / Q000592:standards*; D060753:Water Quality / Q000592:standards*; D014881:Water Supply / Q000592:standards*
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