Children with access to improved sanitation but not improved water are at lower risk of stunting compared to children without access: a cohort study in Ethiopia, India, Peru, and Vietnam

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Abstract

Background

This study’s purpose was to understand associations between water, sanitation, and child growth.

Methods

We estimated stunting (height-for-age Z score <−2 SD) and thinness (BMI-Z <−2 SD) risk ratios using data from 7,715 Ethiopian, Indian, Peruvian, and Vietnamese children from the Young Lives study.

Results

In unadjusted models, household access to improved water and toilets was often associated with reduced stunting risk. After adjusting for child, household, parent, and community variables, access to improved water was usually not associated with stunting nor thinness except in Ethiopia where access to improved water was associated with reduced stunting and thinness at 1y and 5y. In contrast, in both unadjusted and adjusted models, stunting at 1y was less common among children with good toilet access than among those without access and this difference persisted when children were 5y and 8y. For example, in adjusted estimates, Vietnamese 5y olds with access to improved toilets had relative stunting risk at 8y 0.62-0.68 that of 5y olds with no access to improved toilets. Water and toilets were rarely associated with thinness.

Conclusions

Results from our study indicate that access to improved sanitation is more frequently associated with reduced stunting risk than access to improved water. However, additional studies are needed before drawing definitive conclusions about the impact of toilets relative to water. This study is the first to our knowledge to demonstrate the robust and persistent importance of access to improved toilets in infancy, not only during the first year but continuing into childhood. Additional longitudinal investigations are needed to determine concurrent and long-term associations of WASH with stunting and thinness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4033-1) contains supplementary material, which is available to authorized users.

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Most cited references 33

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Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

Deon Filmer, Lant H. Pritchett (2001)

Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.

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Water, sanitation and hygiene for the prevention of diarrhoea

Sandy Cairncross, Caroline Hunt, Sophie Boisson … (2010)

Background Ever since John Snow’s intervention on the Broad St pump, the effect of water quality, hygiene and sanitation in preventing diarrhoea deaths has always been debated. The evidence identified in previous reviews is of variable quality, and mostly relates to morbidity rather than mortality. Methods We drew on three systematic reviews, two of them for the Cochrane Collaboration, focussed on the effect of handwashing with soap on diarrhoea, of water quality improvement and of excreta disposal, respectively. The estimated effect on diarrhoea mortality was determined by applying the rules adopted for this supplement, where appropriate. Results The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese. Conclusion We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

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Multi-country analysis of the effects of diarrhoea on childhood stunting.

William Checkley, Gillian Buckley, Robert Gilman … (2008)

Diarrhoea is an important cause of death and illness among children in developing countries; however, it remains controversial as to whether diarrhoea leads to stunting. We conducted a pooled analysis of nine studies that collected daily diarrhoea morbidity and longitudinal anthropometry to determine the effects of the longitudinal history of diarrhoea prior to 24 months on stunting at age 24 months. Data covered a 20-year period and five countries. We used logistic regression to model the effect of diarrhoea on stunting. The prevalence of stunting at age 24 months varied by study (range 21-90%), as did the longitudinal history of diarrhoea prior to 24 months (incidence range 3.6-13.4 episodes per child-year, prevalence range 2.4-16.3%). The effect of diarrhoea on stunting, however, was similar across studies. The odds of stunting at age 24 months increased multiplicatively with each diarrhoeal episode and with each day of diarrhoea before 24 months (all P or=5 diarrhoeal episodes before 24 months was 25% (95% CI 8-38%) and that attributed to being ill with diarrhoea for >or=2% of the time before 24 months was 18% (95% CI 1-31%). These observations are consistent with the hypothesis that a higher cumulative burden of diarrhoea increases the risk of stunting.

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Author and article information

Contributors

Kirk A. Dearden: kirkdearden@imaworldhealth.org

Whitney Schott: wschott@pop.upenn.edu

Benjamin T. Crookston: benjamin_crookston@byu.edu

Debbie L. Humphries: debbie.humphries@yale.edu

Mary E. Penny: mpenny@iin.sld.pe

Jere R. Behrman: jbehrman@econ.upenn.edu

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 23 January 2017

Publication date PMC-release: 23 January 2017

Publication date Collection: 2017

Volume: 17

Electronic Location Identifier: 110

Affiliations

[1 ]IMA World Health, Dar es Salaam, Tanzania

[2 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Population Studies Center, , University of Pennsylvania, ; Philadelphia, PA USA

[3 ]ISNI 0000 0004 1936 9115, GRID grid.253294.b, Department of Health Science, , Brigham Young University, ; Provo, UT USA

[4 ]ISNI 0000000419368710, GRID grid.47100.32, Department of Epidemiology, , Yale University, ; New Haven, CT USA

[5 ]ISNI 0000 0001 2236 6140, GRID grid.419080.4, , Instituto de Investigación Nutricional, ; Lima 12, Peru

Article

Publisher ID: 4033

DOI: 10.1186/s12889-017-4033-1

PMC ID: 5259877

PubMed ID: 28114914

SO-VID: 9a8062be-ac63-49b2-94d7-118ccbd35ee9

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 12 July 2016

Date accepted : 13 January 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;

Award ID: OPP1032713

Award Recipient : Jere R. Behrman

Funded by: FundRef http://dx.doi.org/10.13039/100009633, Eunice Kennedy Shriver National Institute of Child Health and Human Development;

Award ID: R01 HD070993

Award Recipient : Kirk A. Dearden

Funded by: FundRef http://dx.doi.org/10.13039/501100004828, Grand Challenges Canada;

Award ID: 0072-03

Award Recipient : Kirk A. Dearden

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ScienceOpen disciplines: Public health

Keywords: water,sanitation,stunting,thinness

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ScienceOpen disciplines: Public health

Keywords: water, sanitation, stunting, thinness

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Children with access to improved sanitation but not improved water are at lower risk of stunting compared to children without access: a cohort study in Ethiopia, India, Peru, and Vietnam

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Abstract

Background

Methods

Results

Conclusions

Electronic supplementary material

Related collections

UCL: UN SDG 06 Clean Water and Sanitation

Most cited references 33

Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

Water, sanitation and hygiene for the prevention of diarrhoea

Multi-country analysis of the effects of diarrhoea on childhood stunting.

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