Transcript Slide 1

Association Between Intensive
Handwashing Promotion and Child
Development in Karachi, Pakistan:
A Cluster Randomized Controlled Trial
Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM. Association
between intensive handwashing promotion and child development in Karachi,
Pakistan: a cluster randomized controlled trial. Arch Pediatr Adolesc Med.
Published online September 17, 2012. doi:10.1001/archpediatrics.2012.1181.
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Introduction
•
Background
– Approximately 200 million children are at risk for impaired development
due to environmental and social conditions.
– The determinants of child development are complex and multifactorial,
but include diarrhea and stunting.
– Handwashing promotion has been associated with substantial reductions
in diarrheal and respiratory disease burdens among children.
• Effects of handwashing on child growth and development are
unknown.
•
Study Objective
– To evaluate associations between handwashing promotion and child
growth and development.
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Methods
•
Photo courtesy of HOPE
Setting
– Informal settlements in Karachi, Pakistan, that typically receive at least 2
hours of running water per week.
•
Study Design
– Neighborhoods were randomized to control (n = 9), handwashing
promotion (n = 9), or handwashing and drinking water treatment (n = 10)
during original trial in 2003.
– Handwashing promotion consisted of weekly handwashing education
and provision of free soap as needed for 9 months.
•
Outcomes/Analyses
– Developmental quotients and anthropometric measurements of children
at ages 5-7 years (several years after the original trial).
– Analyses were design adjusted and by intent to treat.
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Methods
•
Limitations
– 16% of the eligible households were lost to follow-up.
– Battelle Developmental Inventory II was not validated for use in Pakistan, but:
• The instrument was translated and adapted carefully for the study
population.
• Effect size is reported relative to controls measured with the same
instrument.
– Study population resided in an area with a large burden of diarrheal disease
and extensive environmental contamination.
• Results may not be generalizable to other settings.
– Study was not designed to assess mechanisms underlying growth or
developmental effects.
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Results
•
Participants
– Households
• 461 households enrolled.
• Households that reenrolled were similar to those that did not.
– Derived from 391 eligible households (84%).
– Children
• One child in target age range was randomly selected from each
household:
– Control
160 children
– Handwashing
141 children
– Handwashing + water treatment
160 children
• Parental literacy, household size and income, breastfeeding exposure,
and school exposure of the reenrolled children were similar across study
groups.
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Results
Developmental Quotients by Study Group
(Control Group and Combined Handwashing Groups)
Group
Effect Size
Control
Handwashing
Absolute
Mean (95% CI)
Mean (95% CI)
Mean (95% CI)
98.3 (93.1 to 103.4)
104.4 (101.9 to 107.0)
6.1 (0.4 to 11.8)
0.4
.04
Adaptive
107.9 (102.7 to 113.1)
112.0 (110.0 to 114.1)
4.1 (-1.4 to 9.7)
0.3
.14
Personal-social
106.6 (103.2 to 110.0)
110.3 (108.3 to 112.2)
3.7 (-0.2 to 7.5)
0.2
.06
Communication
99.7 (95.1 to 104.4)
105.7 (103.5 to 107.8)
5.9 (0.9 to 11.0)
0.4
.02
Cognitive
91.1 (85.0 to 97.3)
97.4 (94.1 to 100.7)
6.2 (-0.7 to 13.2)
0.4
.08
Motor
90.3 (84.7 to 96.0)
96.2 (92.9 to 99.5)
5.9 (-0.6 to 12.4)
0.4
.08
Domain
Global
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SD
P
Value
Results
Anthropometric Measurements by Study Group
Z Score
Control
Handwashing
Handwashing +
Water Treatment
(n = 9 Clusters and
160 Participants)
(n = 9 Clusters and
141 Participants)
(n = 10 Clusters and
160 Participants)
Mean (95% CI)
Mean (95% CI)
Mean (95% CI)
P
Value
Height for age
-1.09 (-1.46 to -0.72)
-1.12 (-1.40 to -0.84)
-1.22 (-1.44 to -1.01)
.46
Weight for age
-1.55 (-1.85 to -1.26)
-1.52 (-1.79 to -1.26)
-1.69 (-1.90 to -1.47)
.39
Body mass index
for age
-1.29 (-1.54 to -1.04)
-1.19 (-1.35 to -1.03)
-1.34 (-1.57 to -1.10)
.75
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Comment
•
In this study, children randomized to intensive handwashing promotion early
in life had global developmental quotients 0.4 SD higher than control
children at ages 5-7 years.
– Similar improvements were found across adaptive, personal-social,
communication, cognitive, and motor domains.
– This effect size is comparable to those reported for early intervention
programs for premature infants and a publicly funded preschool
program in the United States.
•
Undernutrition was common, and anthropometric measurements were not
associated with handwashing intervention.
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Comment
•
The mechanisms underpinning these findings are unclear but may be
related to the following:
– Decreased exposure to pathogens and less immune stimulation.
• Intervention children experienced less than half the diarrhea of
control children in 2003.
– Greater interaction with the environment resulting from:
• Less time spent ill.
• Parents engaging children to wash hands throughout each day.
•
Additional efforts should be undertaken to understand the processes
described and to promote handwashing quickly and efficiently.
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Contact Information
•
If you have questions, please contact the corresponding author:
– Anna Bowen, MD, Centers for Disease Control and Prevention, 1600
Clifton Road NE, MS C-09, Atlanta, GA 30333 ([email protected]).
Photo courtesy of Stephen Luby
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
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