Can integrated interventions create the conditions that support caregiving for better child growth?
Authors: Purnima Menon, Edward A Frongillo
Journal: The Lancet Global Health (2018)

Children born to healthy mothers who live in homes with piped water and improved sanitation, are fed adequate diets, and have appropriate health care have better growth outcomes. Yet intervention trials to test the effects of integrated delivery of specific interventions that address elements of these determinants—such as the Articles by Stephen Luby and colleagues1Luby S Rahman M Arnold BF et al.Effects of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial.Lancet Glob Health. 2018; (published online Jan 29.)http://dx.doi.org/10.1016/S2214-109X(17)30490-4Summary Full Text Full Text PDF Scopus (344) Google Scholar and Clair Null and colleagues2Null C Stewart CP Pickering AJ et al.Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster randomised controlled trial.Lancet Glob Health. 2018; (published online Jan 29.)http://dx.doi.org/10.1016/S2214-109X(18)30005-6Summary Full Text Full Text PDF Scopus (318) Google Scholar reported in this issue of The Lancet Global Health—have come up short. The two studies were well designed and conducted in contexts where the burden of malnutrition is high and water quality, sanitation, handwashing, and nutrition practices are inadequate. We congratulate the study teams for their ambitious efforts at developing, implementing, and evaluating this set of integrated interventions that target major risk factors for poor child growth (water quality, sanitation, and nutrient intake) in tight timeframes and in two different contexts. The findings offer important lessons in intervention delivery and uptake and they force us to think about the implications of what integrated interventions aim to do. First, in Bangladesh,1Luby S Rahman M Arnold BF et al.Effects of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial.Lancet Glob Health. 2018; (published online Jan 29.)http://dx.doi.org/10.1016/S2214-109X(17)30490-4Summary Full Text Full Text PDF Scopus (344) Google Scholar where intervention delivery and adherence was high, the findings raise questions about the convergence with other components of caregiving that affect children's diets, sanitation behaviours, and consequently, growth.3Bronfenbrenner U Morris PA The bioecological model of human development.in: Damon W Lerner RM Handbook of child psychology I. John Wiley & Sons, Hoboken, NJ2007: 795-825Crossref Google Scholar Second, in Kenya,2Null C Stewart CP Pickering AJ et al.Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster randomised controlled trial.Lancet Glob Health. 2018; (published online Jan 29.)http://dx.doi.org/10.1016/S2214-109X(18)30005-6Summary Full Text Full Text PDF Scopus (318) Google Scholar where intervention delivery was suboptimal (especially in the second year when promotion visits dropped sharply), the findings call into question the implementation factors that are necessary to support effective delivery, including worker motivation, supportive supervision, and refresher training. Both implementation and utilisation, in context, deserve further explanation and investigation and we look forward to more on this from the authors. The absence of a synergistic effect from the sanitation and nutrition interventions in the two studies highlight the restricted ability of specific interventions to fully address multiple determinants of child growth. Optimal growth and development are influenced by thousands of caregiving behaviours that together create an enabling microenvironment for each child. For example, a child will need to be fed at least 3000 times between birth and 24 months (an average of five times a day) and will need to be cleaned after urination and defecation just as often. Countless more interactions are needed to soothe a child to sleep, stimulate their brain, and keep them safe. What proportion of this staggering number of interactions are responsive to specific interventions that are likely to be able to support child growth without equivalent efforts to change the context for caregiving beyond what even the best implemented interventions can reach? Theories in child development and nutrition ask that we consider in research and policy what conditions best enable optimal caregiving. Urie Bronfenbrenner's4Engle PL Menon P Haddad L Care and nutrition: concepts and measurement.World Dev. 1999; 27: 1309-1337Crossref Scopus (183) Google Scholar bioecological model of child development places the caregiving dyad (parent and child) and its interactions at the centre of development. His elegant model reminds us that the role of household environments, society, economics, and policy is to shape and support dyadic interactions that are, in totality, nurturing, responsive, and stimulating. About two decades ago, we highlighted that investments in supportive resources for caregiving—a set of factors that surround this dyad—are essential for caregiving that can support growth and development.5Huicho L Segura ER Huayanay-Espinoza CA et al.Child health and nutrition in Peru within an antipoverty political agenda: a countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar These models lead us to ask what instruments can most effectively create the conditions that enable, support, and strengthen the thousands of caregiving interactions linked to feeding, cleaning, stimulating, and protecting children in the first 2 years of life. The reason that the nutrient supplement intervention used in these studies was effective at easing conditions for infant feeding was probably because it assured availability of a nutritious, accessible, palatable, and safe food supplement that was convenient and fit easily into daily feeding routines. By contrast, the water, sanitation, and handwashing interventions were potentially unable to fit similarly into routine caregiving. The absence of a synergistic effect in these studies could be because one component supported and shaped daily caregiving effectively while the other did not. A key message of the studies is not that these determinants—water, sanitation, hygiene, nutrition, and information—do not matter for child growth. Indeed, they matter so much that we, as a community, need to redouble our efforts to identify how best to improve conditions to support caregiving behaviours that contribute effectively to child growth and development. Policy instruments that are equity enhancing and explicitly aim to create conditions to support parenting and caregiving could be the way to achieve this. In some countries, including Peru5Huicho L Segura ER Huayanay-Espinoza CA et al.Child health and nutrition in Peru within an antipoverty political agenda: a countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar and Brazil,6Monteiro CA Benicio MH Conde WL et al.Narrowing socioeconomic inequality in child stunting: the Brazilian experience,1974–2007.Bull World Health Organ. 2010; 88: 305-311Crossref PubMed Scopus (170) Google Scholar social programmes and policy instruments related to sanitation, health, and food security have improved growth and development by putting some, if not all, of these conditions in place.7Gillespie S Hodge J Yosef S et al.Nourishing millions: stories of change in nutrition. International Food Policy Research Institute, Washington, DC2016Google Scholar Actions that support better child growth are socially and biologically complex, and Bronfenbrenner reminds us that every child grows and develops in an exquisitely individual environment. Intervention researchers and social policy experts should continue to build knowledge on how best to shape conditions that support this individual-focused caregiving that every child needs. We declare no competing interests. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trialNutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions. Full-Text PDF Open AccessEffects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trialBehaviour change messaging combined with technologically simple interventions such as water treatment, household sanitation upgrades from unimproved to improved latrines, and handwashing stations did not reduce childhood diarrhoea or improve growth, even when adherence was at least as high as has been achieved by other programmes. Counselling and supplementation in the nutrition group and combined water, sanitation, handwashing, and nutrition interventions led to small growth benefits, but there was no advantage to integrating water, sanitation, and handwashing with nutrition. Full-Text PDF Open Access