***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The impact of improved water , sanitation , and hygiene ( WASH ) access on mitigating illness is well documented , although impact of school-based WASH on school-aged children has not been rigorously explored . We conducted a cluster-r and omized trial in Nyanza Province , Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary -school pupils . Two study population s were used : schools with a nearby dry season water source and those without . Pupils attending ' water-available ' schools that received hygiene promotion and water treatment ( HP&WT ) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools . Those pupils in schools that received only the HP&WT showed similar results . Pupils in ' water-scarce ' schools that received a water-supply improvement , HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness . Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea Diarrhoeal disease is still one of the major causes of mortality and morbidity of children in developing countries . Our objective was to assess the prevalence of diarrhoeal disease among male schoolchildren in Jeddah and to identify the associated risk factors , especially those related to drinking water and sanitation disposal . This cross-sectional study was conducted r and omly where self-administered question naires were issued to parents through the schools . The data were collected from 1,064 respondents indicating that 14.9 % of the children had diarrhoea during the previous month . The main risk factors were : the number of children under five years living in the same house ( OR per child 1.34 , 95 % confidence intervals 1.15 - 1.56 ) , being of Saudi nationality ( OR 1.75 , 1.08 - 2.84 ) , reporting sewage spillage near the home ( OR 1.69 , 1.14 - 2.53 ) , eating out after school hours ( OR 1.74 , 1.16 - 2.60 ) , not drying h and s after washing them ( OR 1.66 , 1.10 - 2.51 ) , using reusable cloths or sponges to dry dishes ( OR 1.70 , 1.14 - 2.52 ) Background Information on the part that poor food-hygiene practice s play a role in the development of diarrhea in low socioeconomic urban communities is lacking . This study was therefore aim ed at assessing the contribution of food-hygiene practice to the prevalence of diarrhea among Indonesian children . Methods A cross-sectional study was conducted among 274 r and omly selected children aged 12–59 months in selected low socioeconomic urban areas of East Jakarta . The prevalence of diarrhea was assessed from 7-day records on frequency and consistency of the child ’s defecation pattern . Food-hygiene practice s including mother ’s and child ’s h and washing , food preparation , cleanliness of utensils , water source and safe drinking water , habits of buying cooked food , child ’s bottle feeding hygiene , and housing and environmental condition were collected through home visit interviews and observations by fieldworkers . Thirty-six practice s were scored and classified into poor ( median and below ) and better ( above median ) food-hygiene practice s. Nutritional status of children , defined anthropometrically , was measured through height and weight . Results Among the individual food-hygiene practice s , children living in a house with less dirty sewage had a significantly lower diarrhea prevalence compared to those who did not [ adjusted odds ratio ( OR ) 0.16 , 95 % confidence interval ( CI ) = 0.03 - 0.73 ] . The overall food-hygiene practice score was not significantly associated with diarrhea in the total group , but it was in children aged < 2 years ( adjusted OR 4.55 , 95 % CI = 1.08 - 19.1 ) . Conclusions Overall poor mother ’s food-hygiene practice s did not contribute to the occurrence of diarrhea in Indonesian children . However , among children < 2 years from low socioeconomic urban areas they were associated with more diarrhea In response to a recorded increasing incidence of diarrhoea in Tumpat District , Malaysia , a case-control study was performed to identify modifiable risk factors for the transmission of diarrhoea , in children aged 4 - 59 months . Ninety-eight pairs of children , matched on age and sex , were recruited prospect ively from health centres . Exposure status was determined during a home visit . Interviewers were ' blinded ' as to the disease status of each child . Odds ratios were measured through matched pair analysis and conditional logistic regression . Risk factors for diarrhoea identified were : reported -- drinking of unboiled water , storage of cooked food before consumption and bottle feeding ; and observations -- animals inside the house and absence of washing water in latrines . Water quality , source of drinking water , reported h and washing behaviour , indiscriminate defecation by children , cup use and the absence of a functional latrine were not associated with diarrhoea . Nonsignificant associations were found for : accessibility of washing water source , type of water storage container and use of fly covers for food Summary Background Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes . We aim ed to assess whether water quality , sanitation , and h and washing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering . Methods The WASH Benefits Bangladesh cluster-r and omised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years ' follow-up . Pregnant women in geographically adjacent clusters were block-r and omised to one of seven clusters : chlorinated drinking water ( water ) ; up grade d sanitation ( sanitation ) ; promotion of h and washing with soap ( h and washing ) ; combined water , sanitation , and h and washing ; counselling on appropriate child nutrition plus lipid-based nutrient supplements ( nutrition ) ; combined water , sanitation , h and washing , and nutrition ; and control ( data collection only ) . Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women . Masking was not possible for data collection , but analyses were masked . Analysis was by intention to treat . This trial is registered at Clinical Trials.gov , number NCC01590095 . Findings Between May 31 , 2012 , and July 7 , 2013 , 5551 pregnant women in 720 clusters were r and omly allocated to one of seven groups . 1382 women were assigned to the control group ; 698 to water ; 696 to sanitation ; 688 to h and washing ; 702 to water , sanitation , and h and washing ; 699 to nutrition ; and 686 to water , sanitation , h and washing , and nutrition .  331 ( 6 % ) women were lost to follow-up . Data on diarrhoea at year 1 or year 2 ( combined ) were available for 14 425 children ( 7331 in year 1 , 7094 in year 2 ) and data on length-for-age Z score in year 2 were available for 4584 children ( 92 % of living children were measured at year 2 ) . All interventions had high adherence . Compared with a prevalence of 5·7 % ( 200 of 3517 child weeks ) in the control group , 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation ( 61 [ 3·5 % ] of 1760 ; prevalence ratio 0·61 , 95 % CI 0·46–0·81 ) , h and washing ( 62 [ 3·5 % ] of 1795 ; 0·60 , 0·45–0·80 ) , combined water , sanitation , and h and washing ( 74 [ 3·9 % ] of 1902 ; 0·69 , 0·53–0·90 ) , nutrition ( 62 [ 3·5 % ] of 1766 ; 0·64 , 0·49–0·85 ) , and combined water , sanitation , h and washing , and nutrition ( 66 [ 3·5 % ] of 1861 ; 0·62 , 0·47–0·81 ) ; diarrhoea prevalence was not significantly lower in children receiving water treatment ( 90 [ 4·9 % ] of 1824 ; 0·89 , 0·70–1·13 ) . Compared with control ( mean length-for-age Z score −1·79 ) , children were taller by year 2 in the nutrition group ( mean difference 0·25 [ 95 % CI 0·15–0·36 ] ) and in the combined water , sanitation , h and washing , and nutrition group ( 0·13 [ 0·02–0·24 ] ) . The individual water , sanitation , and h and washing groups , and combined water , sanitation , and h and washing group had no effect on linear growth . Interpretation Nutrient supplementation and counselling  modestly improved linear growth , but there was no benefit to the integration of water , sanitation , and h and washing with nutrition . Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment . Combined water , sanitation , and h and washing interventions provided no additive benefit over single interventions . Funding Bill & Melinda Gates Foundation Introduction Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development . Water quality , sanitation , h and washing and nutritional interventions can independently reduce enteric infections and growth faltering . There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children . The objective of the WASH Benefits study is to help fill this knowledge gap . Methods and analysis WASH Benefits includes two cluster-r and omised trials to assess improvements in water quality , sanitation , h and washing and child nutrition — alone and in combination — to rural households with pregnant women in Kenya and Bangladesh . Geographically matched clusters ( groups of household compounds in Bangladesh and villages in Kenya ) will be r and omised to one of six intervention arms or control . Intervention arms include water quality , sanitation , h and washing , nutrition , combined water+sanitation+h and washing ( WSH ) and WSH+nutrition . The studies will enrol newborn children ( N=5760 in Bangladesh and N=8000 in Kenya ) and measure outcomes at 12 and 24 months after intervention delivery . Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea . Secondary outcomes include stunting prevalence , markers of environmental enteropathy and child development scores ( verbal , motor and personal/social ) . We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests . Ethics and dissemination Study protocol s have been review ed and approved by human subjects review boards at the University of California , Berkeley , Stanford University , the International Centre for Diarrheal Disease Research , Bangladesh , the Kenya Medical Research Institute , and Innovations for Poverty Action . Independent data safety monitoring boards in each country oversee the trials . This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California , Berkeley . Registration Trial registration identifiers ( http://www . clinical trials.gov ) : NCT01590095 ( Bangladesh ) , NCT01704105 ( Kenya ) Lack of access to safe water and sanitation contributes to diarrhoea moribidity and mortality in developing countries . We evaluated the impact of household water treatment , latrines , shallow wells , and rainwater harvesting on  diarrhoea incidence in rural Kenyan children . We compared diarrhoea rates in 960 children aged < 5 years in 556 households in 12 r and omly selected intervention villages and six r and omly selected comparison villages during weekly home visits over an 8-week period . On multivariate analysis , chlorinating stored water  [ relative risk ( RR ) 0.44 , 95 % confidence interval ( CI ) 0.28 - 0.69 ] , latrine presence ( RR 0.71 , 95 % CI 0.54 - 0.92 ) , rainwater use ( RR 0.70 , 95 % CI 0.52 - 0.95 ) , and living in an intervention village ( RR 0.31 , 95 % CI 0.23 - 0.41 ) , were independently associated with lower diarrhoea risk . Diarrhoea risk was higher among shallow well users ( RR 1.78 , 95 % CI 1.12 - 2.83 ) . Chlorinating stored water , latrines  , and  rainwater use all decreased diarrhoea risk ; combined interventions may have increased health impact This epidemiological investigation examines the impact of several environmental sanitation conditions and hygiene practice s on diarrhea occurrence among children under five years of age living in an urban area . The case-control design was employed ; 997 cases and 999 controls were included in the investigation . Cases were defined as children with diarrhea and controls were r and omly selected among children under five years of age . After logistic regression adjustment , the following variables 
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However , these were marred by flawed studies and inappropriately averaged effects across widely heterogeneous interventions and context s. Our meta-analyses highlight that the overall effect of sanitation on diarrhea was largely driven by sewerage and interventions that improved more than sanitation alone .
There is no true overall effect of sanitation because variability between intervention types and implementation context s is too complex to average .