Effects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia

Abstract

Background The Gambia has high rates of under-5 mortality from diarrhoea and pneumonia, peaking during complementary-feeding age. Community-based interventions may reduce complementary-food contamination and disease rates. Methods and findings A public health intervention using critical control points and motivational drivers, delivered February–April 2015 in The Gambia, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up in September–October 2015 and October–December 2017, respectively. After consent for trial participation and baseline data were collected, 30 villages (clusters) were randomly assigned to intervention or control, stratified by population size and geography. The intervention included a community-wide campaign on days 1, 2, 17, and 25, a reminder visit at 5 months, plus informal community-volunteer home visits. It promoted 5 key complementary-food and 1 key drinking-water safety and hygiene behaviours through performing arts, public meetings, and certifications delivered by a team from local health and village structures to all villagers who attended the activities, to which mothers of 6- to 24-month-old children were specifically invited. Control villages received a 1-day campaign on domestic-garden water use. The background characteristics of mother and clusters (villages) were balanced between the trial arms. Outcomes were measured at 6 and 32 months in a random sample of 21–26 mothers per cluster. There were no intervention or research team visits to villages between 6 and 32 months. The primary outcome was a composite outcome of the number of times key complementary-food behaviours were observed as a proportion of the number of opportunities to perform the behaviours during the observation period at 6 months. Secondary outcomes included the rate of each recommended behaviour; microbiological growth from complementary food and drinking water (6 months only); and reported acute respiratory infections, diarrhoea, and diarrhoea hospitalisation. Analysis was by intention-to-treat analysis adjusted by clustering. (Registration: PACTR201410000859336). We found that 394/571 (69%) of mothers with complementary-feeding children in the intervention villages were actively involved in the campaign. No villages withdrew, and there were no changes in the implementation of the intervention. The intervention improved behaviour adoption significantly. For the primary outcome, the rate was 662/4,351(incidence rate [IR] = 0.15) in control villages versus 2,861/4,378 (IR = 0.65) in intervention villages (adjusted incidence rate ratio [aIRR] = 4.44, 95% CI 3.62–5.44, p < 0.001), and at 32 months the aIRR was 1.17 (95% CI 1.07–1.29, p = 0.001). Secondary health outcomes also improved with the intervention: (1) mother-reported diarrhoea at 6 months, with adjusted relative risk (aRR) = 0.39 (95% CI 0.32–0.48, p < 0.001), and at 32 months, with aRR = 0.68 (95% CI 0.48–0.96, p = 0.027); (2) mother-reported diarrhoea hospitalisation at 6 months, with aRR = 0.35 (95% CI 0.19–0.66, p = 0.001), and at 32 months, with aRR = 0.38 (95% CI 0.18–0.80, p = 0.011); and (3) mother-reported acute respiratory tract infections at 6 months, with aRR = 0.67 (95% CI 0.53–0.86, p = 0.001), though at 32 months improvement was not significant (p = 0.200). No adverse events were reported. The main limitations were that only medium to small rural villages were involved. Obtaining laboratory cultures from food at 32 months was not possible, and no stool microorganisms were investigated. Conclusions We found that low-cost and culturally embedded behaviour change interventions were acceptable to communities and led to short- and long-term improvements in complementary-food safety and hygiene practices, and reported diarrhoea and acute respiratory tract infections. Trial registration The trial was registered on the 17th October 2014 with the Pan African Clinical Trial Registry in South Africa with number (PACTR201410000859336) and 32-month follow-up as an amendment to the trial.

Benefits and Risks of Smallholder Livestock Production on Child Nutrition in Low- and Middle-Income Countries

“…Two articles ( 270 , 271 ) evaluated the effects of improved hygiene practices on reduction of microorganisms in foods and found a significant reduction in fecal contamination of the food samples 3 weeks after training of mothers. Only one RCT measured not only the intermediate outcome (adoption rate of improved behavior) but also a health-related outcome ( 272 ); children's diarrhea was significantly reduced by 60 and 30% at 6 months and 32 months post-intervention, respectively, suggesting noteworthy short and long-term effects of the community-level intervention.…”

“…The remaining 10 records included 3 cluster randomized controlled trials (cRCTs) (263,264,272), 1 cluster-randomized before-after study (265), 1 experimental study (270), and 5 observational studies (266)(267)(268)(269)271). These studies primarily evaluated the uptake of improved complementary food hygiene behaviors among mothers and caregivers in LMIC.…”

Cost‐effectiveness of a weaning food safety and hygiene programme in rural Gambia

“…Full details of the intervention are published elsewhere [22]. In brief, we developed a low-intensity, communitybased behaviour change intervention for weaning food safety and hygiene [17].…”

“…For each stratum, 15 villages were randomly chosen, and within the villages, 20 households were randomly chosen to conduct interviews and observations. The 15 villages from one of the strata were treated with the intervention while the other stratum was the control group [22].…”

“…Trial data were used to estimate the impact of the intervention on the prevalence of childhood diarrhoea 1 and the impact on healthcare resource use, productivity and wider household costs. The effectiveness of the intervention on childhood diarrhoea prevalence at the household level was calculated using a mixed-effect Poisson model with a log-link and adjusted for village-level stratification [22]. The cost associated with a diarrhoeal episode was then attached to the estimates of the effectiveness of the intervention to calculate overall savings associated with a reduction in childhood diarrhoea prevalence.…”