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      Water, Sanitation, and Hygiene: Linkages with Stunting in Rural Ethiopia


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          Stunting is a global burden affecting nearly 160 million children younger than five years of age. Whilst the linkages between nutrition and stunting are well recognized, there is a need to explore environmental factors such as water and sanitation, which may influence feeding practices and result in potential infection pathways. This paper explores the linkages between stunting and water, sanitation and hygiene (WASH) factors in Ethiopia, which is a relatively understudied context. The research draws upon baseline data for children under the age of five from 3200 households across four regions in Ethiopia as part of a wider study and integrated program led by the United Nations Children’s Fund (UNICEF). Using World Health Organization (WHO) z-scoring, the average stunting rate in the sample is 47.5%. This paper also takes into account demographic and social behavioural factors such as the age, gender of children, and gender of the primary caregiver, in addition to handwashing behaviour and drinking water facilities. The evidence recommends efforts to improve handwashing behaviour for mothers and children with a focus on access to clean water. Higher stunting rates with an increase in the age of children highlight the need for continued interventions, as efforts to improve nutrition and WASH behaviours are most effective early on in promoting long-term health outcomes for children.

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          Most cited references42

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          Maternal and child undernutrition and overweight in low-income and middle-income countries

          The Lancet, 382(9890), 427-451
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            Effect of washing hands with soap on diarrhoea risk in the community: a systematic review

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              Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial

              Summary Background Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. Methods We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. Findings Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08–0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28–2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. Interpretation Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. Funding Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.

                Author and article information

                Int J Environ Res Public Health
                Int J Environ Res Public Health
                International Journal of Environmental Research and Public Health
                09 October 2019
                October 2019
                : 16
                : 20
                : 3793
                [1 ]Department of Civil, Environment and Geomatic Engineering, University College London, Chadwick Building, London WC1E6BT, UK; c.kwami@ 123456ucl.ac.uk (C.S.K.); h.a.gavilan@ 123456gmail.com (H.G.)
                [2 ]United Nations Children’s Fund (UNICEF), Regional Water and Sanitation Advisor for East and Southern Africa, Nairobi 00100, Kenya; sgodfrey@ 123456unicef.org
                [3 ]UCL-Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK; m.lakhanpaul@ 123456ucl.ac.uk
                [4 ]Whittington Health NHS Trust, London N19 5NF, UK
                Author notes
                Author information
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                : 30 June 2019
                : 27 September 2019

                Public health
                stunting,wash,child health,hand-washing,environmental health,clean water,evidence-based policy-making,behaviour change,undernutrition


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