Menu ENN Search

The WASH benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea

View this article as a pdf

Research snapshot1

Globally, stunting is the most prevalent form of child undernutrition and is only modestly responsive to dietary interventions. Numerous observational studies have shown that water quality, sanitation, and handwashing (WASH) in a household are strongly associated with linear growth of children living in the same household, which may be partially mediated through diarrhoea, but primarily through environmental enteric dysfunction. Three randomised efficacy trials (SHINE) were undertaken to test improved household-level WASH with and without improved infant and young child feeding (IYCF) on child stunting and diarrhoea in Bangladesh, Kenya, and Zimbabwe. SHINE was a two-by-two factorial trial with four groups: IYCF (counselling on complementary feeding and provision of small-quantity, lipid-paste-nutrient supplement); WASH (combined sanitation, water chlorination and handwashing with soap); IYCF combined with WASH; and standard care. In all trials, the IYCF intervention modestly but significantly increased mean length-for-age (LAZ) by 0.13-0.25 (about one eighth of the deficit of the average child aged 18-24 months). A significant relative reduction in diarrhoea of 31-40% was observed in the water-chlorination intervention under WASH Bangladesh only. In all three trials, the WASH interventions had no effect on linear growth, and providing WASH concurrently with IYCF had no additional benefit on linear growth compared with providing IYCF alone.

These findings are inconsistent with existing and often-cited observational evidence. Further analysis suggests baseline sanitation was a strong risk for stunting. However, the relationship between household WASH indicators and child linear growth may be confounded. The effect on diarrhoea in Bangladesh is likely due to the regular visits to participating household (six times per month), compared to monthly in Kenya and Zimbabwe. Such intense contact is not possible at scale. The authors conclude that these trials were not effective enough in reducing the faecal-oral transmission of pathogens to result in linear growth and optimal health, with children having high rates of enteric infection. Future research should explore interventions that are radically more effective in reducing faecal contamination in the domestic environment (‘transformative WASH’) and, irrespective of intervention, strengthened support is required for governance systems of financing, operations, monitoring, evaluation, and regulation.

Read more...

Endnotes

1Pickering, A.J., Null, C., Winch, P.J., Mangwadu, G., Arnold, B.F., Prendergast, A.J. et al (2019) The WASH benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. Lancet Glob Health 2019; 7: e1139–46

More like this

FEX: Independent and combined effects of improved WASH and improved complementary feeding on child stunting and anaemia in rural Zimbabwe

Summary of research1 Location: Zimbabwe What we know: Stunting and anaemia remain prevalent in children; plausible interventions have shown limited or inconsistent...

FEX: WASH interventions and their effects on the nutritional status of children

Summary of research1 Location: Global What we know: Water, sanitation and hygiene (WASH) interventions are frequently implemented to improve health and reduce infectious...

FEX: Evaluation of an integrated health-nutrition-WASH project to reduce malnutrition prevalence in children under two in Bangladesh

By Monsurul Hoq and John Brogan Monsurul Hoq was working as a Statistician Epidemiologist during the study. He has experience in monitoring and evaluation of community-based...

FEX: Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali

Summary of research1 Location: Mali What we know: Community-led total sanitation (CLTS) is being scaled up, but there is limited evidence on child health impacts. What this...

FEX: Are studies underestimating the effects of sanitation on child nutrition?

Summary of published letter1 A recently published letter in The Lancet comments on a study published in the same publication by Pickering et al (2015), who studied the effects...

FEX: Is exposure to animal faeces harmful to child nutrition and health outcomes?

Summary of research1 Location: Ethiopia, Bangladesh and Vietnam What we know: Sub-clinical environmental enteric disorder (EED) is an important causal pathway from poor...

FEX: Impact evaluation of WASH in nutrition intervention on morbidity and acute malnutrition in Niger

View this article as a pdf Lisez cet article en français ici By SaïdouTamboura, Dr Moussa IssaLende and Lucia Pantella Tamboura Saïdou has worked in...

FEX: Complementary food hygiene: An overlooked opportunity in the WASH, nutrition and health sectors

Summary of research1 Location: Global What we know: Poor food hygiene may account for a substantial proportion of diarrhoeal diseases and contribute to malnutrition among...

FEX: Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review

Summary of research* Location: Global What we know: Diarrhoea is commonly associated with SAM; carbohydrate malabsorption may be a contributing factor. What this article...

NEX: The effect of interventions to improve water quality and supply, provide sanitation and promote handwashing with soap on physical growth in children (Cochrane review)

Alan D Dangour et al. Cochrane Library 2013, Issue 7 Available online http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0057931/ In low-income countries an estimated 165 million...

FEX: Association of early interventions with birth outcome and child linear growth in low-income and middle-income countries

View this article as a pdf Research snapshot1 The first 1,000 days of life represent a critical window for child development. Pregnancy and the exclusive breastfeeding (EBF)...

FEX: Using trials of improved practices to shift nutrition and hygiene behaviours in Sierra Leone

By Jennifer Pietropaoli, Philip Moses and Heather Forrester View this article as a pdf Jennifer Pietropaoli is the Outreach and Communications Officer for the SPRING Project....

NEX: Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links

Francis M. Ngure et. Al. Annals of the New York Academy of Sciences, Volume 1308, Every Child's Potential: Integrating Nutrition and Early Childhood Development...

FEX: Improving nutritional outcomes of rural households through a community-based approach in Ethiopia

View this article as a pdf By Haimanot Abebe, Lioul Berhanu, Wossen Assefa Negash and Daniel Abbott Haimanot Abebe is a Communication and Reporting Specialist working for...

FEX: Deterioration of children with MAM who have no access to supplementary feeding programmes

James P, Sadler K, Wondafrash M, Argaw A, Luo H, Geleta B, et al. (2016) Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience...

FEX: Nutrition-sensitive agriculture: What have we learned and where do we go from here?

Summary of research1 Location: Global What we know: Agriculture has strong potential to improve nutrition outcomes through improving food availability and access and through...

FEX: WASHplus in Mali: integrating WASH and nutrition for healthy communities

By Renuka Bery, Sahada Traore and Lonna Shafritz Lisez cet article en français ici Renuka Bery is the Integration Manager of the WASHplus project managed by FHI 360....

NEX: The power of WASH: why sanitation matters for nutrition

Summary of Chapter 3 of the 2014-2015 Global Food Policy Report by Dean Spears and Lawrence Haddad, available on IFPRI website. Water, sanitation, and hygiene (WASH) can have...

FEX: The missing ingredients: Are policy-makers doing enough on water, sanitation and hygiene to end malnutrition?

News Summary of report* Location: Global What we know: There are many pathways linking poor WASH with undernutrition; how 'integration' of WASH and nutrition interventions...

Combining WASH and nutrition activities within a multisectoral package to improve young children’s diets and reduce child stunting in Sindh province, Pakistan

View this article as a pdf Dr Sahib Jan Badar is the Programme Coordinator of the Accelerated Action Plan, Department of Health, Government of Sindh province. Eric Alain...

Close

Reference this page

The WASH benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. Field Exchange 61, November 2019. p38. www.ennonline.net/fex/61/washbenefits

(fex.61.564)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.