Reproducibility package for Effects of a community-driven water, sanitation, and hygiene intervention on diarrhea, child growth, and local institutions: a cluster-randomized controlled trial in rural Democratic Republic of Congo

Background. Diarrhea and growth faltering in early childhood reduce survival and impair neurodevelopment. We assessed whether a national program combining (i) funds for latrine and water upgrades; (ii) institutional strengthening; and (iii) behavior change campaigns reduced diarrhea and stunting, and strengthened local institutions.
Methods and Findings. We collaborated with program implementers to conduct a cluster-randomized controlled trial in four provinces of the Democratic Republic of Congo. 332 rural villages were grouped into 121 clusters to minimize geographic spillovers. Between 15 March and 30 June 2018, we randomly assigned, after stratifying by province and cluster size, 50 intervention and 71 control clusters. Masking of participants and interviewers was not possible. Primary outcomes were length-for-age Z score among children under 5 years of age, caregiver-reported diarrhea in last 7 days among children under 5 years of age, and an index of community WASH institutions. The primary analysis was on an intention-to-treat basis, using a binary variable indicating whether the participant was in an intervention or control cluster. The trial was registered with the Pan African Clinical Trials Registry, number PACTR202102616421588 and the American Economics Association RCT registry, number AEARCTR-0004648.
1,971 households were interviewed between Nov 2022 and April 2023, median 3.5 years post-intervention. The intervention did not affect 7-day diarrhea prevalence (adjusted mean 44 difference -0.01 [95% CI -0.05– 0.03]) or length-for-age (adjusted mean difference -0.01 [95ECI -0.15–0.12]). Intervention villages scored 0.40 SD higher (95% CI 0.16–0.65) on the WASH institutions index.
Conclusions. The DRC’s national rural WASH program increased access to improved water and sanitation infrastructure, and created new WASH institutions, all of which persisted for at least 3.5 years. However, these effects were not sufficient to reduce diarrhea or growth faltering.