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Published in: BMC Public Health 1/2017

Open Access 01-12-2017 | Research article

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

Authors: Kirk A. Dearden, Whitney Schott, Benjamin T. Crookston, Debbie L. Humphries, Mary E. Penny, Jere R. Behrman, The Young Lives Determinants and Consequences of Child Growth Project Team

Published in: BMC Public Health | Issue 1/2017

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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.
Appendix
Available only for authorised users
Footnotes
1
The United Nations definition of sanitation includes collection, storage, treatment, disposal, reuse, and recycling of human excreta; drainage, disposal, recycling, and re-use of wastewater, stormwater and household, industrial and hazardous solid waste. Young Lives includes household access to improved water and improved toilets. We use ‘improved toilets’ and ‘improved water,’ where ‘improved’ means that children had access to improved water or toilets, not that access improved between data collection rounds. We do not know which children were consuming safe water, as improved water may be contaminated between sources and use.
 
2
Information on handwashing is not available for all four countries so associations between handwashing and children’s nutritional status are not addressed.
 
3
We constructed asset indices [55] using first principal components of nine consumer durables (bike, car, fridge, mobile phone, motorbike, telephone, radio, sewing machine, television), five housing quality indicators (cooking fuel quality, roofing material, wall material, floor material, electricity availability), household ownership, and number of rooms per person. The first principal component is consistent with 23.7% of the variance for Ethiopia, 22.5% for India, 26.0% for Peru and 26.0% for Vietnam.
 
4
Community data were reported by community leaders.
 
5
We constructed “community wealth” as average asset indices for other households in the same cluster.
 
6
We were not able to allow error clustering in binomial analysis because the modified Poisson regression estimation requires use of the sandwich estimator of variance. We allowed for clustering by community in the continuous analysis of HAZ and BMI (Additional file 1: Tables S2–S5), using the Stata robust command.
 
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Metadata
Title
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
Authors
Kirk A. Dearden
Whitney Schott
Benjamin T. Crookston
Debbie L. Humphries
Mary E. Penny
Jere R. Behrman
The Young Lives Determinants and Consequences of Child Growth Project Team
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2017
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-017-4033-1

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