Stewart Christine P, Kariger Patricia, Fernald Lia, Pickering Amy J, Arnold Charles D, Arnold Benjamin F, Hubbard Alan E, Dentz Holly N, Lin Audrie, Meerkerk Theodora J, Milner Erin, Swarthout Jenna, Colford John M, Null Clair
Department of Nutrition, University of California, Davis, CA, USA.
School of Public Health, University of California, Davis, CA, USA.
Lancet Child Adolesc Health. 2018 Apr;2(4):269-280. doi: 10.1016/S2352-4642(18)30025-7.
Poor nutrition and infectious diseases can prevent children from reaching their developmental potential. We aimed to assess the effects of improvements in water, sanitation, handwashing, and nutrition on early child development in rural Kenya.
In this cluster-randomised controlled trial, we enrolled pregnant women in their second or third trimester from three counties (Kakamega, Bungoma, and Vihiga) in Kenya's western region, with an average of 12 households per cluster. Groups of nine geographically adjacent clusters were block-randomised, using a random number generator, into the six intervention groups (including monthly visits to promote target behaviours), a passive control group (no visits), or a double-sized active control group (monthly household visits to measure child mid-upper arm circumference). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at year 1, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at year 2. Masking of participants was not possible, but data assessors were masked. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105.
Between Nov 27, 2012, and May 21, 2014, 8246 women residing in 702 clusters were enrolled. No clusters were lost to follow-up, but 2212 households with 2279 children were lost to follow-up by year 2. 5791 (69%) children were measured at year 1 and 6107 (73%) at year 2. At year 1, compared with the active control group, the combined water, sanitation, handwashing, and nutrition group had greater rates of attaining the standing with assistance milestone (hazard ratio 1·23, 95% CI 1·09-1·40) and the walking with assistance milestone (1·32, 1·17-1·50), and the handwashing group had a greater rate of attaining the standing alone milestone (1·15, 1·01-1·31). There were no differences when comparing the other intervention groups with the active control group on any of the motor milestone measures at year 1. At year 2, there were no differences among groups for the communication, gross motor, personal social, or combined EASQ scores.
The handwashing and combined water, sanitation, handwashing, and nutrition interventions might have improved child motor development after 1 year, although after 2 years there were no other differences between groups. Future research should examine ways to make community health and nutrition programmes more effective at supporting child development.
Bill & Melinda Gates Foundation.
营养不良和传染病会阻碍儿童发挥其发育潜能。我们旨在评估改善水、环境卫生、洗手和营养状况对肯尼亚农村地区儿童早期发育的影响。
在这项整群随机对照试验中，我们招募了肯尼亚西部地区三个县（卡卡梅加、邦戈马和维希加）妊娠中期或晚期的孕妇，每个整群平均有12户家庭。使用随机数字生成器将九个地理相邻的整群组进行区组随机分组，分为六个干预组（包括每月进行家访以促进目标行为）、一个被动对照组（无家访）或一个双倍规模的主动对照组（每月进行家访以测量儿童的中上臂围）。六个干预组分别为：氯化饮用水；改善环境卫生；用肥皂洗手；水、环境卫生和洗手综合措施；通过咨询和提供基于脂质的营养补充剂改善营养；水、环境卫生、洗手和营养综合措施。在此，我们报告预先设定的儿童发育次要结局：1岁时使用世界卫生组织模块评估的大运动里程碑达成情况，以及2岁时通过扩展年龄与阶段问卷（EASQ）测量的沟通、大运动、个人社交和综合得分。无法对参与者进行设盲，但对数据评估者进行了设盲。分析采用意向性分析。本试验已在ClinicalTrials.gov注册，注册号为NCT01704105。
2012年11月27日至2014年5月21日期间，702个整群中的8246名妇女入组。无整群失访，但到第2年时，有2212户家庭（含2279名儿童）失访。1岁时对5791名（69%）儿童进行了测量，2岁时对6107名（73%）儿童进行了测量。1岁时，与主动对照组相比，水、环境卫生、洗手和营养综合措施组达到在帮助下站立里程碑（风险比1.23，95%置信区间1.09 - 1.40）和在帮助下行走里程碑（1.32，1.17 - 1.50）的比例更高，洗手组达到独自站立里程碑的比例更高（1.15，1.01 - 1.31）。在1岁时的任何大运动里程碑测量中，将其他干预组与主动对照组进行比较时均无差异。2岁时，各干预组在沟通、大运动、个人社交或EASQ综合得分方面无差异。
洗手以及水、环境卫生、洗手和营养综合措施干预可能在1年后改善了儿童的运动发育，尽管2年后各干预组之间没有其他差异。未来的研究应探讨如何使社区卫生和营养项目在支持儿童发育方面更有效。
比尔及梅琳达·盖茨基金会。
