The Impact and Sustainability of Multisector Interventions to Improve Water Quality and Food Safety in Complex Environments: A Cluster-Randomized Controlled Trial in Northern Uganda

In complex environments characterized as protracted humanitarian settings where public services are largely lacking, food and water contamination are significant contributors to malnutrition. Multisector, multilevel, community-driven programs may address these issues simultaneously and synergistically. A 1:1:1 cluster randomized controlled design was used to evaluate the effectiveness of two social and behavior change interventions in northern Uganda aimed at enabling participants to assess and act on key drivers of malnutrition: a core nutrition impact and positive practice (NIPP) intervention versus an NIPP+ intervention, which included additional nudges toward adopting improved technologies, compared with a control arm (NCT04209569). Primary outcomes included concentrations of Escherichia coli ( E. coli ) and total coliform in household water (baseline n = 359), total maize aflatoxins (parts per billion; baseline n = 271), and women’s serum aflatoxin B1-lysine (nanograms (ng)/mL and picograms (pg)/mg albumin, baseline n = 452). Data were collected at three time points: baseline (pre-intervention), endline (post-intervention), and sustainability (1 year post-intervention). The NIPP+ intervention, but not the NIPP intervention, significantly reduced the risk of household E. coli water contamination at endline (RR = 0.76; 95% CI = 0.59–0.97), but this effect was not sustained. No significant intervention effects on maize aflatoxins or serum aflatoxin B1 were found. These findings highlight the need to examine factors that prevent sustained water quality gains, including structural barriers to behavior change and innovation adoption. Additionally, intervention groups may not have received sufficient exposure to market vendors, leading to less adoption of new technologies. Future interventions may benefit from improved program implementation and strengthened market connections for obtaining technologies and selling agricultural products.