@article{contreras_islam_mertens_pickering_arnold_benjamin-chung_hubbard_rahman_unicomb_luby_et al._2024, title={Improved Child Feces Management Mediates Reductions in Childhood Diarrhea from an On-Site Sanitation Intervention: Causal Mediation Analysis of a Cluster-Randomized Trial in Rural Bangladesh}, volume={3}, ISSN={["2210-6014"]}, DOI={10.1007/s44197-024-00210-y}, abstractNote={Abstract Background The WASH benefits Bangladesh trial multi-component sanitation intervention reduced diarrheal disease among children < 5 years. Intervention components included latrine upgrades, child feces management tools, and behavioral promotion. It remains unclear which components most impacted diarrhea. Methods We conducted mediation analysis within a subset of households (n = 720) from the sanitation and control arms. Potential mediators were categorized into indicators of latrine quality, latrine use practices, and feces management practices. We estimated average causal mediation effects (ACME) as prevalence differences (PD), defined as the intervention’s effect on diarrhea through its effect on the mediator. Results The intervention improved all indicators compared to controls. We found significant mediation through multiple latrine use and feces management practice indicators. The strongest mediators during monsoon seasons were reduced open defecation among children aged < 3 and 3–8 years, and increased disposal of child feces into latrines. The strongest mediators during dry seasons were access to a flush/pour-flush latrine, reduced open defecation among children aged 3–8 years, and increased disposal of child feces into latrines. Individual mediation effects were small (PD = 0.5–2 percentage points) compared to the overall intervention effect but collectively describe significant mediation pathways. Discussion The effect of the WASH Benefits Bangladesh sanitation intervention on diarrheal disease was mediated through improved child feces management and reduced child open defecation. Although the intervention significantly improved latrine quality, relatively high latrine quality at baseline may have limited benefits from additional improvements. Targeting safe child feces management may increase the health benefits of rural sanitation interventions. }, journal={JOURNAL OF EPIDEMIOLOGY AND GLOBAL HEALTH}, author={Contreras, Jesse D. and Islam, Mahfuza and Mertens, Andrew and Pickering, Amy J. and Arnold, Benjamin F. and Benjamin-Chung, Jade and Hubbard, Alan E. and Rahman, Mahbubur and Unicomb, Leanne and Luby, Stephen P. and et al.}, year={2024}, month={Mar} } @article{islam_contreras_unicomb_rahman_arnold_colford_luby_thomas_ercumen_2025, title={Sensor-measured versus reported latrine use to characterize sanitation intervention uptake in a randomized controlled trial among households in rural Bangladesh}, volume={264}, ISSN={["1618-131X"]}, DOI={10.1016/j.ijheh.2024.114511}, journal={INTERNATIONAL JOURNAL OF HYGIENE AND ENVIRONMENTAL HEALTH}, author={Islam, Mahfuza and Contreras, Jesse D. and Unicomb, Leanne and Rahman, Mahbubur and Arnold, Benjamin F. and Colford, John M. and Luby, Stephen P. and Thomas, Evan A. and Ercumen, Ayse}, year={2025}, month={Mar} } @article{contreras_islam_mertens_pickering_arnold_benjamin-chung_hubbard_rahman_unicomb_luby_et al._2022, title={Evaluation of an on-site sanitation intervention against childhood diarrhea and acute respiratory infection 1 to 3.5 years after implementation: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh}, volume={19}, ISSN={["1549-1676"]}, url={http://dx.doi.org/10.1371/journal.pmed.1004041}, DOI={10.1371/journal.pmed.1004041}, abstractNote={ Background Diarrhea and acute respiratory infection (ARI) are leading causes of death in children. The WASH Benefits Bangladesh trial implemented a multicomponent sanitation intervention that led to a 39% reduction in the prevalence of diarrhea among children and a 25% reduction for ARI, measured 1 to 2 years after intervention implementation. We measured longer-term intervention effects on these outcomes between 1 to 3.5 years after intervention implementation, including periods with differing intensity of behavioral promotion. Methods and findings WASH Benefits Bangladesh was a cluster-randomized controlled trial of water, sanitation, hygiene, and nutrition interventions (NCT01590095). The sanitation intervention included provision of or upgrades to improved latrines, sani-scoops for feces removal, children’s potties, and in-person behavioral promotion. Promotion was intensive up to 2 years after intervention initiation, decreased in intensity between years 2 to 3, and stopped after 3 years. Access to and reported use of latrines was high in both arms, and latrine quality was significantly improved by the intervention, while use of child feces management tools was low. We enrolled a random subset of households from the sanitation and control arms into a longitudinal substudy, which measured child health with quarterly visits between 1 to 3.5 years after intervention implementation. The study period therefore included approximately 1 year of high-intensity promotion, 1 year of low-intensity promotion, and 6 months with no promotion. We assessed intervention effects on diarrhea and ARI prevalence among children <5 years through intention-to-treat analysis using generalized linear models with robust standard errors. Masking was not possible during data collection, but data analysis was masked. We enrolled 720 households (360 per arm) from the parent trial and made 9,800 child observations between June 2014 and December 2016. Over the entire study period, diarrheal prevalence was lower among children in the sanitation arm (11.9%) compared to the control arm (14.5%) (prevalence ratio [PR] = 0.81, 95% CI 0.66, 1.00, p = 0.05; prevalence difference [PD] = −0.027, 95% CI −0.053, 0, p = 0.05). ARI prevalence did not differ between sanitation (21.3%) and control (22.7%) arms (PR = 0.93, 95% CI 0.82, 1.05, p = 0.23; PD = −0.016, 95% CI −0.043, 0.010, p = 0.23). There were no significant differences in intervention effects between periods with high-intensity versus low-intensity/no promotion. Study limitations include use of caregiver-reported symptoms to define health outcomes and limited data collected after promotion ceased. Conclusions The observed effect of the WASH Benefits Bangladesh sanitation intervention on diarrhea in children appeared to be sustained for at least 3.5 years after implementation, including 1.5 years after heavy promotion ceased. Existing latrine access was high in the study setting, suggesting that improving on-site latrine quality can deliver health benefits when latrine use practices are in place. Further work is needed to understand how latrine adoption can be achieved and sustained in settings with low existing access and how sanitation programs can adopt transformative approaches of excreta management, including safe disposal of child and animal feces, to generate a hygienic home environment. Trial registration ClinicalTrials.gov; NCT01590095; https://clinicaltrials.gov/ct2/show/NCT01590095. }, number={8}, journal={PLOS MEDICINE}, publisher={Public Library of Science (PLoS)}, author={Contreras, Jesse D. and Islam, Mahfuza and Mertens, Andrew and Pickering, Amy J. and Arnold, Benjamin F. and Benjamin-Chung, Jade and Hubbard, Alan E. and Rahman, Mahbubur and Unicomb, Leanne and Luby, Stephen P. and et al.}, editor={Bhutta, Zulfiqar A.Editor}, year={2022}, month={Aug} } @article{contreras_islam_mertens_pickering_kwong_arnold_benjamin-chung_hubbard_alam_sen_et al._2022, title={Influence of community-level sanitation coverage and population density on environmental fecal contamination and child health in a longitudinal cohort in rural Bangladesh}, volume={245}, ISSN={["1618-131X"]}, url={http://dx.doi.org/10.1016/j.ijheh.2022.114031}, DOI={10.1016/j.ijheh.2022.114031}, abstractNote={Household-level sanitation interventions have had limited effects on child health or environmental contamination, potentially due to low community coverage. Higher community-level coverage with safely managed sanitation can reduce opportunities for disease transmission.}, journal={INTERNATIONAL JOURNAL OF HYGIENE AND ENVIRONMENTAL HEALTH}, publisher={Elsevier BV}, author={Contreras, Jesse D. and Islam, Mahfuza and Mertens, Andrew and Pickering, Amy J. and Kwong, Laura H. and Arnold, Benjamin F. and Benjamin-Chung, Jade and Hubbard, Alan E. and Alam, Mahfuja and Sen, Debashis and et al.}, year={2022}, month={Aug} } @article{contreras_islam_mertens_pickering_kwong_arnold_benjamin-chung_hubbard_alam_sen_et al._2021, title={Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh}, volume={55}, ISSN={["1520-5851"]}, DOI={10.1021/acs.est.1c01114}, abstractNote={Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1–3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.}, number={12}, journal={ENVIRONMENTAL SCIENCE & TECHNOLOGY}, author={Contreras, Jesse D. and Islam, Mahfuza and Mertens, Andrew and Pickering, Amy J. and Kwong, Laura H. and Arnold, Benjamin F. and Benjamin-Chung, Jade and Hubbard, Alan E. and Alam, Mahfuja and Sen, Debashis and et al.}, year={2021}, month={Jun}, pages={8169–8179} }