title: Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: a cluster randomised trial.
abstract: Effective prevention and control of diarrhoea requires caregivers to comply with a suite of proven measures, including exclusive breastfeeding, handwashing with soap, correct use of oral rehydration salts, and zinc administration. We aimed to assess the effect of a novel behaviour change intervention using emotional drivers on caregiver practice of these behaviours.
  
  
  
  We did a cluster randomised controlled trial in Lusaka Province, Zambia. A random sample of 16 health centres (clusters) were selected from a sampling frame of 81 health centres in three of four districts in Lusaka Province using a computerised random number generator. Each cluster was randomly assigned 1:1 to either the intervention-clinic events, community events, and radio messaging-or to a standard care control arm, both for 6 months. Primary outcomes were exclusive breastfeeding (self-report), handwashing with soap (observation), oral rehydration salt solution preparation (demonstration), and zinc use in diarrhoea treatment (self-report). We measured outcome behaviours at baseline before start of intervention and 4-6 weeks post-intervention through repeat cross-sectional surveys with mothers of an infant younger than 6 months and primary caregivers of a child younger than 5 years with recent diarrhoea. We compared outcomes on an intention-to-treat population between intervention and control groups adjusted for baseline behaviour. The study was registered with ClinicalTrials.gov, number NCT02081521.
  
  
  
  Between Jan 20 and Feb 3, 2014, we recruited 306 mothers of an infant aged 0-5 months (156 intervention, 150 standard care) and 343 primary caregiver of a child aged 0-59 months with recent diarrhoea (176 intervention, 167 standard care) at baseline. Between Oct 20 to Nov 7, 2014, we recruited 401 mothers of an infant 0-5 months (234 intervention, 167 standard care) and 410 primary caregivers of a child 0-59 months with recent diarrhoea (257 intervention, 163 standard care) at endline. Intervention was associated with increased prevalence of self-reported exclusive breastfeeding of infants aged 0-5 months (adjusted difference 10·5%, 95% CI 0·9-19·9). Other primary outcomes were not affected by intervention. Cluster intervention exposure ranged from 11-81%, measured by participant self-report with verification questions. Comparison of control and intervention clusters with coverage greater than 35% provided strong evidence of an intervention effect on oral rehydration salt solution preparation and breastfeeding outcomes.
  
  
  
  The intervention may have improved exclusive breastfeeding (assessed by self-reporting), but intervention effects were diluted in clusters with low exposure. Complex caregiver practices can improve through interventions built around human motives, but these must be implemented more intensely.
  
  
  
  Absolute Return for Kids (ARK) and Comic Relief.
authors.affiliation: Department for Disease Control, London School of Hygiene & Tropical Medicine, London, UK. Electronic address: katie.greenland@lshtm.ac.uk.
authors.forename: Katie
authors.initials: K
authors.lastname: Greenland
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Jenala
authors.initials: J
authors.lastname: Chipungu
authors.affiliation: Department for Disease Control, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Val
authors.initials: V
authors.lastname: Curtis
authors.affiliation: Department for Disease Control, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Wolf-Peter
authors.initials: WP
authors.lastname: Schmidt
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Zumbe
authors.initials: Z
authors.lastname: Siwale
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Mweetwa
authors.initials: M
authors.lastname: Mudenda
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Joyce
authors.initials: J
authors.lastname: Chilekwa
authors.affiliation: Medical Research Council Tropical Epidemiology Group, Department for Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: James J
authors.initials: JJ
authors.lastname: Lewis
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Roma
authors.initials: R
authors.lastname: Chilengi
mesh_terms: D001942:Breast Feeding; D002675:Child, Preschool; D016000:Cluster Analysis; D003430:Cross-Sectional Studies; D003967:Diarrhea / Q000517:prevention & control* / Q000628:therapy; D005260:Female; D006235:Hand Disinfection / Q000379:methods; D015438:Health Behavior; D006293:Health Promotion; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009035:Mothers / Q000523:psychology; D057566:Self Report; D015024:Zambia