Can child-focused sanitation and nutrition programming improve health practices and outcomes? Evidence from a randomised controlled trial in Kitui County, Kenya

Abstract

IntroductionIn Kenya’s Kitui County, 46% of children under 5 years are stunted. Sanitation and nutrition programmes have sought to reduce child undernutrition, though they are typically implemented separately. We evaluate the effectiveness of an integrated sanitation and nutrition (SanNut) intervention in improving caregiver sanitation and nutrition knowledge and behaviours.MethodsWe conducted a cluster-randomised controlled trial to evaluate the impact of the SanNut intervention on caregiver knowledge, sanitary and hygiene practices, sanitation outcomes and nutrition outcomes. The evaluation included caregivers of children under 5 years across 604 villages in Kitui County. 309 treatment villages were randomly assigned to receive both the SanNut intervention and the standard Community-Led Total Sanitation (CLTS) intervention, while 295 control villages only received the CLTS intervention. 8 households with children under 5 years were randomly selected from each evaluation village to participate in the endline survey, for a total of 4322 households.ResultsSanNut led to modest improvements in sanitary knowledge and practices emphasised by the programme. Caregivers in treatment villages were 3.3 pp (+32%) more likely to mention lack of handwashing after handling child faeces as a potential cause of diarrhoea, and 4.9 pp (+7.8%) more likely to report safe disposal of child faeces than caregivers in control villages. Treatment households were 1.9 pp (+79%) more likely to have a stocked handwashing station and 2.9 pp (−16%) less likely to report incidences of child diarrhoea. However, SanNut appears to have had no impact on nutritional practices, such as breastfeeding, vitamin A supplementation or deworming. Non-child outcomes traditionally associated with CLTS, including latrine use and homestead sanitary conditions, were similar in treatment and control groups.ConclusionChild-focused messaging can potentially be integrated into CLTS programming, though this integration was more successful for topics closer to CLTS objectives (sanitation practices, including limiting faecal contamination and handwashing) than for more disparate topics (nutritional practices).Trial registrationPan-African Clinical Trials Registry (PACTR201803003159346) and American Economic Association registry for randomised controlled trials (AEARCTR-0002019).

How community engagement in water and sanitation interventions impacts human health, infrastructure and service longevity in low- and middle-income countries: a realist review

“…Ongoing external monitoring can hold communities accountable for changing their health and sanitation behaviours (35,38,42,45), leading to improved health of children as seen in height and weight changes and diarrhoea occurrence (35). Without ongoing external monitoring, loss of momentum for change can occur, halting behaviour change progress (23).…”

“…They spread innovations by using their shared knowledge of the language, social, cultural and religious beliefs and their existing relationships with and within communities (30,31). Innovators and early adopters in a community include teachers (30,55), leaders (10,22,30,31,34,55,56), healthcare workers (30,42,55,57,58), and community committees (21,46,59,60). Diffusion can contribute to the three outcomes -access, change and sustainability.…”

“…Diffusion can occur through communication among peers, which leads to shared understanding, therefore reinforcing the adoption of new behaviour at an individual or community level(30,31,46,63). Examples of diffusion influencing behaviour change include reduction of open defecation(10,34,45,48,55,65), water purification(63), disposable of rubbish and care of animals(45), and sanitation and hygiene behaviours(60), which may lead to improved health outcomes such as reduction in diarrhoea rates and waterborne diseases(42,60). Behaviour change is also further enabled by diffusion in communities with high levels of social cohesion and connectedness -by enabling communication among peers, to build and share knowledge(46,62), and as highly regarded leaders influence the spread of new behaviour and create new social norms through their endorsement(11,20,34,55).…”

Antecedents and consequences of adopting CLTS among tribal communities to become open defecation free: case study on Indian Swachh Bharat Abhiyan

“…The following steps have been undertaken in this study to carry out a systematic review as per PRISMA model below (Figure 1). The findings of the majority of studies about health and hygiene indicate that there is a significant improvement of the health and hygiene conditions in the communities (Biran 2018;Deng 2020;Gebremariam 2018Gebremariam , 2019Gimaiyo 2019;Hürlimann 2018;Husaini 2019;Jung 2016;Mlenga 2016;Njuguna 2016;Safari 2019;Tutuanita 2019;Yeboah-Antwi 2019). The cost and benefit analysis of CLTS implementation programs reveals that CLTS interventions can yield promising cost-effective returns, particularly if rigorous follow-up post-triggering is implemented and uptake of improved latrines is achieved (Biran 2018;Cha 2020;Ficek 2019;Holm 2016;Kayoka 2019;Woode 2018).…”

How community participation in water and sanitation interventions impacts human health, WASH infrastructure and service longevity in low-income and middle-income countries: a realist review

“…Internal monitoring can be conducted by a chief or village headman,10 21 38 locally trained volunteers,48 community members40 51 or by the community’s health, water or community—total led sanitation committee 37 39 41 45 46 48 50. External monitoring can be conducted by NGO facilitators,40 44 health workers39 43 52 or political leaders and council officials 37…”