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A 7-year follow-up of an early water, sanitation, hygiene, and nutrition intervention in rural Bangladesh

Sat, March 25, 3:15 to 4:45pm, Salt Palace Convention Center, Floor: 1, Grand Ballroom F

Abstract

Background
Water, sanitation and hygiene (WASH) interventions have the potential to improve the developmental trajectories of children through reduced enteric pathogen infection and improved child health and parental care practices (Oriá et al. 2016). A recent cluster-randomized controlled trial in rural Bangladesh (WASH-B trial, ClinicalTrials.gov Identifier: NCT01590095) (Arnold et al. 2013), found that WASH and Nutrition interventions that included the installation of hardware (e.g. water storage containers and chlorine tablets, double pit latrines, handwashing stations), lipid-based nutritional supplements and intensive behavior change communication, when delivered either individually or in combination, contributed to improvements in child development outcomes at 1 and 2 years of age (Tofail et al. 2018). Evidence for sustained effects of early interventions on middle and late childhood can be used to better understand and compare cost-effectiveness of early life interventions, however, few studies to date have followed-up early interventions to evaluate the sustained effects (Jeong, Pitchik, and Fink 2021). The study aimed to understand the middle-childhood effects of Water (W), Sanitation (S), Hygiene (H), Nutrition (N) and combined WSH and WSH+N interventions implemented in the WASH-B cluster randomized controlled trial.

Methods
We conducted a 7-year follow-up of the WASH-B cohort between September 2019-March 2020 and October 2020-February 2021 (with a pause due to the COVID-19 pandemic). Primary outcomes of the 7-year follow-up were (1) cognitive development, as measured by the Full-Scale IQ and other indices of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV), (2) Fine Motor Abilities, based on the Movement Assessment Battery for Children assessment, (3) Social-emotional development, measured with the Strengths and Difficulties Questionnaire, (4) Executive functioning, and (5) School Achievement, assessed followed the principles of the Wide Range Achievement Test. All analyses were intention to treat. For each outcome we used generalized linear models to determine unadjusted and adjusted comparisons between each arm and the control arm, accounting for pair-matching and block level clustering.

Results
Preliminary results from the 7-year follow-up (n=3,832) show that effects persisted in the WSH+N, N, and S arms for multiple of the cognitive development domains of the WPPSI-IV (domains with sustained effects in one or more arms include: Full-Scale IQ, Verbal Comprehension, Fluid Reasoning, Gross Ability, and Nonverbal Function) with effect sizes between 0.10 (95% CI: 0.00, 0.20) and 0.15 (0.03, 0.27) in adjusted analyses for intervention arms with sustained effects. Effects also persisted in all arms except the Sanitation-only arm for prosocial social-emotional development, with effect sizes between 0.21 (0.07, 0.34) and 0.33 (0.17, 0.49) across arms. There were no sustained intervention effects on fine motor, executive functioning, or school achievement. Results across all primary and secondary outcomes will be presented.

Conclusion
This study found persistent effects of early sanitation, hygiene, nutrition, and combined WSH+N interventions on child cognitive and social-emotional development at 6-7 years of age. Interventions to improve child cognitive development outcomes should consider including WASH components to improve children’s environments more holistically. Hypothesized pathways through which this effect is operating are to be discussed.

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