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      Association of Poor Sanitation With Growth Measurements Among Children in India

      research-article
      , MA 1 , , MPA 2 , , , PhD, MPH 2
      JAMA Network Open
      American Medical Association

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          Key Points

          Question

          Is poor sanitation associated with lower height among children older than 5 years in India?

          Findings

          This cross-sectional analysis of 134 882 children and adolescents aged 0 to 18 years in India found that poor sanitation (ie, open defecation and lack of access to boiled or filtered drinking water) was associated with lower height-for-age z scores across all ages in childhood and adolescence.

          Meaning

          Improved sanitation may be associated with greater height across all child ages.

          Abstract

          This cross-sectional study characterizes the association of poor sanitation with height-for-age z scores in children and adolescents in India aged 0 to 18 years.

          Abstract

          Importance

          Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized.

          Objective

          To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years.

          Design, Setting, and Participants

          This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India’s District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019.

          Exposures

          Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water.

          Main Outcomes and Measures

          Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects.

          Results

          The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, −0.22; 95% CI, −0.35 to −0.10; >7 to ≤12 years: β, −0.15; 95% CI, −0.24 to −0.06; >12 to ≤18 years: β, −0.10; 95% CI, −0.19 to −0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, −0.22; 95% CI, −0.33 to −0.12; >12 to ≤18 years: β, −0.16; 95% CI, −0.23 to −0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11).

          Conclusions and Relevance

          In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.

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

            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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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                15 April 2020
                April 2020
                15 April 2020
                : 3
                : 4
                : e202791
                Affiliations
                [1 ]Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle
                [2 ]Program in Public Health, Anteater Instruction and Research Offices, University of California, Irvine
                Author notes
                Article Information
                Accepted for Publication: February 18, 2020.
                Published: April 15, 2020. doi:10.1001/jamanetworkopen.2020.2791
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Chakrabarti S et al. JAMA Network Open.
                Corresponding Author: Parvati Singh, MPA, Program in Public Health, Anteater Instruction and Research Offices, 653 E Peltason Dr, Second Floor, University of California, Irvine, CA 92697-3957 ( parvatis@ 123456uci.edu ).
                Author Contributions: Mr Chakrabarti and Ms Singh had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: All authors.
                Acquisition, analysis, or interpretation of data: All authors.
                Drafting of the manuscript: All authors.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Chakrabarti, Singh.
                Obtained funding: Singh, Bruckner.
                Administrative, technical, or material support: Singh, Bruckner.
                Supervision: Bruckner.
                Conflict of Interest Disclosures: None reported.
                Funding/Support: This research was funded by grant 1R03AI135322-01 from the National Institute of Allergy and Infectious Diseases.
                Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Additional Contributions: We thank the Ministry of Health and Family Welfare, Government of India for the open access to the District Level Household and Facilities Survey, 2012-2013.
                Article
                zoi200139
                10.1001/jamanetworkopen.2020.2791
                7160693
                32293682
                c3d3af10-876f-4186-991a-5e2ca13b34e4
                Copyright 2020 Chakrabarti S et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 15 November 2019
                : 18 February 2020
                Funding
                Funded by: National Institute of Allergy and Infectious Diseases
                Categories
                Research
                Original Investigation
                Online Only
                Public Health

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