***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND The promotion of household water treatment and h and washing with soap has led to large reductions in child diarrhoea in r and omized efficacy trials . Currently , we know little about the health effectiveness of behaviour-based water and hygiene interventions after the conclusion of intervention activities . METHODS We present an extension of previously published design ( propensity score matching ) and analysis ( targeted maximum likelihood estimation ) methods to evaluate the behavioural and health impacts of a pre-existing but non-r and omized intervention ( a 3-year ,  combined household water treatment and h and washing campaign in rural Guatemala ) . Six months after the intervention , we conducted a cross-sectional cohort study in 30 villages ( 15 intervention and 15 control ) that included 600 households , and 929 children < 5 years of age . RESULTS The study design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics . The intervention led to modest gains in confirmed water treatment behaviour [ risk difference = 0.05 , 95 % confidence interval ( CI ) 0.02 - 0.09 ] . We found , however , no difference between the intervention and control villages in self-reported h and washing behaviour , spot-check hygiene conditions , or the prevalence of child diarrhoea , clinical acute lower respiratory infections or child growth . CONCLUSIONS To our knowledge this is the first post-intervention follow-up study of a combined household water treatment and h and washing behaviour change intervention , and the first post-intervention follow-up of either intervention type to include child health measurement . The lack of child health impacts is consistent with unsustained behaviour adoption . Our findings highlight the difficulty of implementing behaviour-based household water treatment and h and washing outside of intensive efficacy trials Background Infectious diseases associated with poor sanitation such as diarrhoea , intestinal worms , trachoma and lymphatic filariasis continue to cause a large disease burden in low income setting s and contribute substantially to child mortality and morbidity . Obtaining health impact data for rural sanitation campaigns poses a number of method ological challenges . Here we describe the design of a village-level cluster-r and omised trial in the state of Orissa , India to evaluate the impact of an ongoing rural sanitation campaign conducted under the umbrella of  India  ’s Total Sanitation Campaign (TSC).We r and omised 50 villages to the intervention and 50 villages to control . In the intervention villages the implementing non-governmental organisations conducted community mobilisation and latrine construction with subsidies given to poor families . Control villages receive no intervention . Outcome measures include ( 1 ) diarrhoea in children under 5 and in all ages , ( 2 ) soil-transmitted helminth infections , ( 3 ) anthropometric measures , ( 4 ) water quality , ( 5 ) number of insect vectors ( flies , mosquitoes ) , ( 6 ) exposure to faecal pathogens in the environment . In addition we are conducting process documentation ( latrine construction and use , intervention reach ) , cost and cost-effectiveness analyses , spatial analyses and qualitative research on gender and water use for sanitation . Results R and omisation result ed in an acceptable balance between trial arms . The sample size requirements appear to be met for the main study outcomes . Delays in intervention roll-out caused logistical problems especially for the planning of health outcome follow-up surveys . Latrine coverage at the end of the construction period ( 55 % ) remained below the target of 70 % , a result that may , however , be in line with many other TSC intervention areas in India . Conclusion We discuss a number of method ological problems encountered thus far in this study that may be typical for sanitation trials . Nevertheless , it is expected that the trial procedures will allow measuring the effectiveness of a typical rural sanitation campaign , with sufficient accuracy and validity INTRODUCTION Pneumonia and diarrhoea are leading causes of death in children . There is a need to develop effective interventions . OBJECTIVE We present the design and baseline findings of a community-r and omised controlled trial in rural Peru to evaluate the health impact of an Integrated Home-based Intervention Package in children aged 6 to 35 months . METHODS We r and omised 51 communities . The intervention was developed through a community-participatory approach prior to the trial . They comprised the construction of improved stoves and kitchen sinks , the promotion of h and washing , and solar drinking water disinfection ( SODIS ) . To reduce the potential impact of non-blinding bias , a psychomotor stimulation intervention was implemented in the control arm . The baseline survey included anthropometric and socio-economic characteristics . In a sub- sample we determined the level of faecal contamination of drinking water , h and s and kitchen utensils and the prevalence of diarrhoegenic Escherichia coli in stool specimen . RESULTS We enrolled 534 children . At baseline all households used open fires and 77 % had access to piped water supplies . E. coli was found in drinking water in 68 % and 64 % of the intervention and control households . Diarrhoegenic E. coli strains were isolated from 45/139 stool sample s. The proportion of stunted children was 54 % . CONCLUSIONS R and omization result ed in comparable study arms . Recently , several critical review s raised major concerns on the reliability of open health intervention trials , because of uncertain sustainability and non-blinding bias . In this regard , the presented trial featuring objective outcome measures , a simultaneous intervention in the control communities and a 12-month follow up period will provide valuable evidence OBJECTIVES To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing  diarrhoea  and the additional benefit of promoting h and washing with soap . METHODS The study was conducted in squatter settlements of Karachi , Pakistan , where diarrhoea is a leading cause of childhood death . Interventions were r and omly assigned to 47 neighbourhoods . Households in 10 neighbourhoods received diluted bleach and a water vessel ; nine neighbourhoods received soap and were encouraged to wash h and s ; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel ; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash h and s ; and nine neighbourhoods were followed as controls . Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea . RESULTS Study participants in control neighbourhoods had diarrhoea on 5.2 % of days . Compared to controls , participants living in intervention neighbourhoods had a lower prevalence of diarrhoea : 55 % ( 95 % CI 17 % , 80 % ) lower in bleach and water vessel neighbourhoods , 51 % ( 95 % CI 12 % , 76 % ) lower in h and washing promotion with soap neighbourhoods , 64 % lower ( 95 % CI 29 % , 90 % ) in disinfectant-disinfectant neighbourhoods , and 55 % ( 95 % CI 18 % , 80 % ) lower in disinfectant-disinfectant plus h and washing with soap neighbourhoods . CONCLUSIONS With an intense community-based intervention and supplies provided free of cost , each of the home-based interventions significantly reduced diarrhoea . There was no benefit by combining h and washing promotion with water treatment Data collected in the late 1980s from eight countries in Sub-Saharan Africa ( Burundi , Ghana , Togo , and Ug and a ) , Asia/North Africa ( Sri Lanka and Morocco ) , and the Americas ( Bolivia and Guatemala ) were combined and analyzed to test whether incremental health effects regarding diarrhea  and  nutritional status result from incremental improvements in water and sanitation conditions . Rural ( n = 11,992 ) and urban ( n = 4,888 ) sample s were analyzed separately . Optimal ( i.e. , on the premises ) and intermediate ( improved public water ) water supplies were compared with unimproved water conditions . Optimal ( flush toilets or water-seal-latrines ) and intermediate ( latrines ) sanitation levels were compared with unimproved sanitation .  Nationally representative ( r and om ) sample s of ever-married women age 15 - 49 years , with or without children , were interviewed in all countries , and children aged 3 - 36 months with available weight and height data were included in the analyses . Multiple linear regression controlled for household , maternal , and child-level variables ; in addition , dummy variables were included for each country . Improvements in sanitation result ed in less diarrhea and in taller and heavier children with each of the three levels of water supply . Incremental benefits in sanitation were associated with less diarrhea and with additional increases in the weights and heights of children . The effects of improved sanitation were greater among urban dwellers than among rural dwellers . Health benefits from improved water were less pronounced than those for sanitation . Benefits from improved water occurred only when sanitation was improved and only when optimal water was present . These findings suggest that public health intervention should balance epidemiologic data with the cost of services and the dem and for water . There should be efforts to develop compatible technologies so that incremental improvements in service can be made Anthropometric data for 1295 children were collected during cross-sectional surveys conducted in Kurunegala District , Sri Lanka between March 1987 and March 1988 . The relationship between anthropometric status and a range of water , sanitation and hygiene-related exposures was examined . After taking account of socioeconomic and other potential confounding factors , some evidence was found that boiling of water was associated with improved height-for-age . It seems unlikely that boiling of water alone could be responsible for the observed increase in height-for-age . Boiling of water may be acting as a " marker " for a range of hygiene and child-care behaviours . No convincing evidence of any other association was found . In particular , water source was not associated with anthropometric status . A concurrent study conducted in the same population found evidence of a substantial reduction in diarrhoea morbidity associated with the use of improved sources . These findings , taken together , lend support to the hypothesis that interventions for the control of diarrhoea may have no detectable impact on anthropometric status OBJECTIVE To evaluate associations between h and washing promotion and  child growth and development  . DESIGN Cluster r and omized controlled trial . SETTING Informal settlements in Karachi , Pakistan . PARTICIPANTS A total of 461 children who were enrolled in a trial of household-level h and washing promotion in 2003 and were younger than 8 years at re assessment in 2009 . INTERVENTIONS In 2003 , neighborhoods were r and omized to control ( n = 9 ) , h and washing promotion ( n = 9 ) , or h and washing promotion and drinking water treatment ( n = 10 ) ; intervention households received free soap and weekly h and washing promotion for 9 months . MAIN OUTCOME MEASURES Anthropometrics and developmental quotients measured with the Battelle Developmental Inventory II at 5 to 7 years of age . RESULTS Overall , 24.9 % ( 95 % CI , 20.0%-30.6 % ) and 22.1 % ( 95 % CI , 18.0%-26.8 % ) of children had z scores that were more than 2 SDs below the expected z scores for height and body mass index for age , respectively ; anthropometrics did not differ significantly across study groups . Global developmental quotients averaged 104.4 ( 95 % CI , 101.9 - 107.0 ) among intervention children and 98.3 ( 95 % CI , 93.1 - 103.4 ) among control children ( P = .04 ) . Differences of similar magnitude were measured across adaptive , personal-social , communication , cognitive , and motor domains . CONCLUSIONS Although growth was similar across groups , children r and omized to the h and washing promotion during their first 30 months of age attained global developmental quotients 0.4 SDs greater than those of control children at 5 to 7 years of age . These gains are comparable to those of at-risk children enrolled in publicly funded preschools in the United States and suggest that h and washing promotion could improve child well-being and societal productivity . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01538953 CONTEXT Washing h and s with soap prevents diarrhea , but children at the highest risk of death from diarrhea are younger than 1 year , too young to wash their own h and s. Previous studies lacked sufficient power to assess the impact of household h and washing on diarrhea in infants . OBJECTIVE To evaluate the effect of promoting household h and washing with soap among children at the highest risk of death from diarrhea . DESIGN , SETTING , AND PARTICIPANTS A cluster r and omized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi , Pakistan . Field workers visited participating households at least weekly from April 15 , 2002 , to April 5 , 2003 . Eligible households located in the study area had at least 2 children younger than 15 years , at least 1 of whom was younger than 5 years . INTERVENTIONS Weekly visits in 25 neighborhoods to promote h and washing with soap after defecation and before preparing food , eating , and feeding a child . Within intervention neighborhoods , 300 households ( 1523 children ) received a regular supply of antibacterial soap and 300 households ( 1640 children ) received plain soap .  Eleven neighborhoods ( 306 households and 1528 children ) comprised the  control group . MAIN OUTCOME MEASURE Incidence density of diarrhea among children , defined as the number of diarrheal episodes per 100 person-weeks of observation . RESULTS Children younger than 15 years living in households that received h and washing promotion and plain soap had a 53 
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None of the studies reported differential impacts relevant to equity issues such as gender , socioeconomic status and religion .
The available evidence from meta- analysis of data from cluster-r and omised controlled trials with an intervention period of 9 - 12 months is suggestive of a small benefit of WASH interventions ( specifically solar disinfection of water , provision of soap , and improvement of water quality ) on length growth in children under five years of age .
Very few studies provided information on intervention adherence , attrition and costs .