Association of childhood undernutrition with water supply, sanitation and hygiene interventions in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: A case-control study

doi:10.21203/rs.2.24114/v2

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Association of childhood undernutrition with water supply, sanitation and hygiene interventions in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: A case-control study

https://doi.org/10.21203/rs.2.24114/v2

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Objective: This study aimed to describe the association of childhood undernutrition with water supply, sanitation, and hygiene interventions in Kersa and Omo Nada districts of the Jimma Zone, Ethiopia.

Design: A case-control study design was undertaken from December 2018 to January 2019.

Setting: Kersa and Omo Nada districts of the Jimma Zone, Ethiopia.

Subjects: 128 cases and 256 controls were randomly selected from malnourished and well-nourished children, respectively.

Outcome measures: Bodyweight, length/height, mid-upper arm circumference and presence of edema of the children were measured according to the WHO references. Then, the nutritional status of children was identified as case or control using cutoff points recommended by the WHO based on the Z-score, edema, and MUAC values recorded.

Results: A total of 378 children were included in this study, with a response rate of 98.44%. Undernutrition was significantly increased among children who delayed breastfeeding initiation (AOR=2.60; 95% CI: 1.02-6.65), diarrhea (AOR=9.50; 95% CI: 5.19-17.36), living with households indexed as the poorest (AOR=2.57; 95% CI: 1.09-6.07) and defecated in a pit latrine without slab/open pit (AOR=2.49; 95% CI: 1.17-5.30), and sometimes practiced hand washing at the critical times (AOR=2.52; 95% CI: 1.10-5.75) compared with their counterparts. However, lactating during the survey (AOR=0.35; 95% CI: 0.18-0.71) and collection and disposal of under-five children feces elsewhere (AOR = 0.08; 95% CI: 0.01-0.75) significantly reduced the likelihood of undernutrition.

Conclusions: Early initiation of exclusive breastfeeding, diarrhea prevention, the use of improved latrine, and always handwashing practices at critical times could be important variables to improve the nutritional status of children.

Health Policy

children

undernutrition

water supply

sanitation

hygiene interventions

Undernutrition is a widely known nutritional disorder and one of the leading causes of morbidity and mortality among children in developing countries like Ethiopia ^1–3. It is one of the main health problems facing women and children in Ethiopia. The country has the second-highest rate of malnutrition in Sub-Saharan Africa. According to the 2016 Ethiopia DHS report, 38%, 10%, and 24% of under-five children were stunted, wasted, and underweight, respectively, and the problem is even worse in rural areas ⁴. Results from the 2019 Ethiopia mini DHS also showed that the prevalence of stunting, wasting, and underweight were 37%, 7%, and 21%, respectively⁵. Similarly, studies done in different parts of Ethiopia revealed that the magnitude of stunting, wasting, and underweight were high and the problem of malnutrition was a public health issue in Ethiopia ^6–8.

Lack of access to highly nutritious foods is a common cause of malnutrition. In addition to this, undernutrition also results from inadequate food intake and infectious diseases like frequent or persistent diarrhea, pneumonia, measles, and malaria⁹. Similarly, food insecurity, inappropriate child care, poor access to health care, an unhealthy environment, including inadequate access to water, sanitation, and hygiene are basic determinants of undernutrition ^10,11. Poor water supply, sanitation, and hygiene (WASH) interventions create perfect conditions for the development of different infectious diseases that are linked to undernutrition^12,13. These poor interventions can affect a child’s nutritional status in at least three direct pathways: via diarrheal diseases, intestinal parasitic infections, and environmental enteropathy. It may indirectly impact the nutritional status of children by necessitating walking long distances in search of water and sanitation facilities and diverting a mother’s time away from childcare¹⁴.

Children themselves may become affected by environmental contamination as they start crawling, walking, exploring, and putting objects in their mouths, which increases the risk of ingesting fecal bacteria from both human and animal sources. This leads to repeated bouts of diarrhea and intestinal worms, which in turn deteriorates the nutritional status of children ^15,16. The WASH benefit and Sanitation, Hygiene, Infant Nutrition Efficacy Project (SHINE)trial report showed that children who received WASH interventions still had high fecal exposure and there were typically ten times higher rates of enteric infection compared with children in high-income countries¹⁷. Moreover, recent study findings reported that there was little or no impact of selected WASH interventions on reducing childhood diarrhea and stunting ^18–21.

Previous studies have shown that socioeconomic factors, poor nutrition, and mothers' lack of awareness and manner of feeding led to an increase in the prevalence of undernutrition^2,22,23. A meta-analysis of data from cluster-randomized controlled trials concluded that WASH interventions had a benefit on the improvement of nutritional status in under-five children²⁴. Specifically, studies done in different parts of Ethiopia showed that the presence of childhood diarrhea, safe disposal of children’s feces, and the use of soap for handwashing were risk factors for childhood undernutrition^8,25,26.

The available evidence revealed that the association between water supply, sanitation, and hygiene interventions and childhood undernutrition is limited in Ethiopia. Thus, this study aimed to describe the association of childhood undernutrition with water supply, sanitation, and hygiene interventions in Kersa and Omo Nada districts of Jimma Zone, Ethiopia. The results of this study could help policymakers, program planners, donors, and concerned bodies to prevent child undernutrition. It may also serve as a baseline for further studies of organizations working in this area.

The conceptual framework (Fig.1) of this study was adapted from a previous done study ²⁴. In the conceptual framework, we tried to show the link between childhood undernutrition and water supply, sanitation, and hygiene interventions.

Study design and setting

A case-control study was conducted in two purposively selected districts (Kersa and Omo Nada) of the Jimma Zone, Oromia Regional State, Ethiopia, from December 2018 to January 2019. The Zonal capital, Jimma town, is located in southwest Ethiopia, 357 km away from Addis Ababa. The Zone extends between 7013’ – 8056’ North latitudes and 35049 -38038’ East longitudes and the altitude ranges from 1740 to 2660 above sea level. Agriculture is the major economic activity and it includes mainly growing coffee and cattle rearing. According to the Jimma Zonal Health Office annual report (2019), the populations of Kersa and Omo Nada were 227,959 and 208,517, respectively. About 81.65% of residents of the Kersa district and 71.7% residents of the Omo Nada district rely on improved drinking water sources in 2018. Currently, the improved latrine coverage of the districts is 40% for Kersa and 39% for Omo Nada ²⁷.

Source population

All children from 6 to 59 months, living in Kersa and Omo Nada districts with Z-scores of weight-for-height (wasting) < -2 (SD), weight-for-age (underweight) < -2 SD, height-for-age (stunting) < -2 SD, mid-upper arm circumference (MUAC) less than 11.5 cm or have edema were the source population of cases, whereas all children from 6 to 59 months with Z-scores of weight-for-height from -2 to +2SD, weight-for-age from -2 to +2SD, height-for-age from -2 to +2SD, or MUAC above 12 cm or have no edema based on growth reference of WHO²⁸ were the source population of controls.

Inclusion and exclusion criteria

All children aged 6-59 months who had malnutrition and whose mothers resided in the study districts for at least a year were included as cases. All children aged 6-59 months of age and had no malnutrition based on the WHO growth reference ²⁸ and whose mothers resided in the studied districts for at least a year were included in the control group. Children whose mothers were seriously ill and could not communicate information were excluded from the study.

Sample size determination and sampling procedure

The sample size was determined using a formula for calculating the double population proportion by assuming estimates of the proportion of well-nourished children (P₂) as 43.8% (taking water sources as a major factor²⁹), α=1.96 at 95% confidence level, odds ratio 1.89; (from literature, children living in households that had been using unprotected water sources were 1.89 times more likely to be acutely malnourished than those who had been using protected water sources ³⁰), power: 80% (0.84), the ratio of cases to controls was 1:2. This implies that 117 cases and 234 controls were required. After adding 10% for the non-response rate, the final samples were 128 for cases and 256 for controls.

Five health centers, which have centers for the treatment of undernourished children, were selected purposively from the two districts. Then, three kebeles (the smallest administrative unit) were selected from each district based on the level of malnutrition reported as high, medium and low kebeles. Census was conducted to identify the number of under-five children and their nutritional status in the kebeles. Then, the cases were randomly selected from the malnourished children and controls were randomly selected from well-nourished children.

Anthropometric measurements

Bodyweight, length/height, mid-upper arm circumference and presence of edema of the children were measured based on the WHO references ²⁸. The weight and height of the children were measured using the Salter scale and measuring board, respectively. The body weight of all children was measured without shoes to the nearest 0.1g, whereas the height/length of children was measured to the nearest 0.1 cm. Each measurement was done twice, and the mean of the two readings was recorded. The weighing scale was calibrated regularly with a known weight. The ace scales' indicator was checked against zero reading after weighing every child. To convert raw anthropometric data (weight, height, and age of children) into an anthropometric Z-score (weight-for-age, height-for-age, and weight-for-height), emergency nutrition assessment (ENA) for standardized monitoring and assessment of relief and transition (SMART) was used. Thumb pressure was applied to the upper side of both feet for three seconds to diagnose the presence of edema. The presence was diagnosed if a bilateral depression (pitting) remained after the press release. Mid-upper arm circumference was measured in centimeters using MUAC tape on the left arm and was recorded to the nearest 0.1 cm. The nutritional status of children was identified as case or control using cutoff points recommended by the World Health Organization based on the Z-score, edema, and MUAC values²⁸. Confirmed malnourished children were linked to the health center after consultation with the data collector.

Data collection instrument

Data were collected by interviewing mothers/caretakers of the children using a pretested questionnaire. The questionnaire was adapted from the WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation, and Hygiene 2017, core questions on water, sanitation, and hygiene for the household survey ³¹. Some questions were revised to suit the context of the study by the principal investigator.

The questionnaire consisted of variables related to socio-demographic, child, water supply, sanitation, and hygiene practices. The wealth index was developed from assets and other housing characteristics. Handwashing at critical times was assessed through information about their handwashing behavior after defecation, before handling food/water, before feeding a child, or after cleaning the child stool. If they responded in the affirmative about these critical times of handwashing, we gave the remark; always; if at least one was missed, we gave the remark; sometimes. Mothers/caregivers were asked about the ages of their children or this information was collected from the immunization cards if present. If they did not know the age or did not have immunization cards, data collectors asked them whether the child was born before or after known holidays and/or local market days. They were also asked about any occurrence of diarrhea and vaccination status based on the age of the child to identify the past two weeks of diarrhea and vaccination of children.

Data collection and quality

The data were collected by health professionals through face-to-face interviews with mothers/caregivers. The questionnaire used for this data collection was originally prepared in English and then translated into the local language (Afan Oromo) and back retranslated into English to check its consistency by public health and linguistics professionals. Then, the necessary correction and modification of the instrument were made.

The mother’s interview and anthropometric measurements were done by data collectors following two days of intensive training, which included orientation, demonstration, and field procedures. Pretest of the instrument and the procedure was conducted on 5% of mothers or caregivers of the children in the selected households before actual data collection. Anthropometric measurements were done by using calibrated and pretested scales. The overall day-to-day data collection process and completeness of the collected questionnaires; was checked and any other amendments were made by supervisors and the principal investigator.

Data analyses

Data were entered, cleaned, and checked for correctness using EpiData version 4.2. After exportation, all statistical analyses were carried out using SPSS version 24. Data were described by frequency, percentage, and mean (for continuous data) to compare the cases and controls. The wealth status of the household was computed from the household’s asset ownership and housing characteristics using principal component analysis³². It was categorized as poor, middle, or rich. The logistic regression model was used to assess whether water supply, sanitation, and hygiene practices are associated with childhood undernutrition. The crude odds ratio (COR) and 95% CI were used to identify the unadjusted strength of association between independent and dependent variables in bivariate analysis. To adjust for confounders, multivariable analysis was used. All variables that had a p-value of 0.25 or less in the bivariate analysis were included in the multivariable analysis after multicollinearity among variables was assessed by calculating the variance inflation factor (VIF). Adjusted odds ratios (AOR) with 95% CI were computed to assess the strength of the association and a p-value < 0.05 was used to declare statistical significance in the multivariable analysis.

Study population characteristics

A total of 378 children (126 cases and 252 controls) were included in this study, with a response rate of 98.44%. The mean age of these children was 31.2 (SD± 8.5) months in cases and 30.1(±12.2) months in controls. Regarding the sex of children, 61.9% of cases and 57.5% of controls were male. Seventy-three percent of cases and 23% of control children had diarrhea at least once in the past two weeks during the visit. The mean age of the mothers was 28.6 (± 3.1) years for cases and 28.1(±2.9) years for controls. Regarding the educational status of the respondents, 44% of cases and 38.9% of controls had no or lack formal education. In this study, 30.16% of cases and 35.32% of controls belonged to the poor wealth index, whereas 31.75% of cases and 34.13% of controls were from good wealth status, respectively (Table 1).

Table 1: Socio-demographic characteristics of study participants of Kersa and Omo Nada districts in Jimma Zone, Ethiopia

Variables		Cases	Controls
Variables		No (%)	No (%)
Age of mother	19-25	31(24.6)	70(27.8)
	26-31	75(59.5)	151(59.9)
	32-39	20(15.9)	31(12.3)
Family size	≤5	43(34.1)	88(34.9)
Family size	>5	83(65.9)	164(65.1)
Number of under-five children in the households	1	77(61.1)	169(67.1)
Number of under-five children in the households	2	49(38.9)	83(32.9)
Educational status of the mother/caregiver of the child	No/lack of formal education	56(44.4)	98(38.9)
Educational status of the mother/caregiver of the child	Literate	70(55.6)	154(61.1)
Sex of the child	Female	48(38.1)	107(42.5)
Sex of the child	Male	78(61.9)	145(57.5)
Initiation of breastfeeding	Delayed (>1 hour of birth)	53(42.1)	41(16.3)
Initiation of breastfeeding	Early(within1 hour of birth)	73(57.9)	211(83.7)
Child breastfeed (Months)	up to 24	92(73.0)	131(52.0)
	still now	22(17.5)	95(37.7)
	Others	12(9.5)	26(10.3)
Age of first introduce liquids or foods to the baby(Months)	Below 6	9(7.1)	5(2.0)
Age of first introduce liquids or foods to the baby(Months)	6	117(92.9)	247(98.0)
Livestock ownership	Yes	16(12.7)	40(15.9)
Livestock ownership	No	110(87.3)	212(84.1)
Had diarrhea at least once in the past two week(s)	Yes	92(73.0)	58(23.0)
Had diarrhea at least once in the past two week(s)	No	34(27.0)	194(77.0)
Wealth index	Poor	38(30.16)	89(35.32)
	Medium	48(38.10)	77(30.56)
	Wealthiest	40(31.75)	86(34.13)

The main sources of drinking water in households in 96.8% of cases and 92.5% of controls were from protected sources. The mean daily water consumption of study participants was 16.2(±27.8) liters per capita per day for cases and 14.9 (±11.2) liters per capita per day for controls. The mean time to fetch water was 45.2(±16.8) minutes for cases and 39.7(±19.5) minutes for controls. In addition, the approximate distances of drinking water sources from the home of both populations were almost less than one km. Sixty-three percent of the case respondents and 75.8% of the control respondents reported that the amount of water collected for domestic purposes was insufficient for their families. Seventy-six percent of cases and 84.8% of controls further explained that the main reason for the inability to access sufficient quantities of water when needed was the unavailability of water in the source. In the home of 91.3% of cases and 93.7% of controls, there were no water treatment practices at the point of use (Table 2).

Table 2: Drinking water supply related characteristics of study participants of Kersa and Omo Nada districts in Jimma Zone, Ethiopia

Variables		Cases	Controls
Variables		No (%)	No (%)
The main source of drinking-water	Protected sources	122(96.8)	223(92.5)
The main source of drinking-water	Unprotected sources	4(3.2)	19(7.5)
The main source of water used by households for cooking and washing	Protected sources	115(91.3)	214(84.9)
	Unprotected sources	11(8.7)	38(15.1)
The distance of drinking water sources (Km)	less than/equal to1	123(97.6)	232(92.1)
The distance of drinking water sources (Km)	greater than 1	3(2.4)	20(7.9)
Time to take to go there, get water, and come back (minutes)	≤30	50(39.7)	130(51.6)
	>30	76(60.3)	122(48.4)
Amount of water get sufficient	Sufficient	47(37.3)	61(24.2)
Amount of water get sufficient	Not sufficient	79(62.7)	191(75.8)
The main reason for unable to access sufficient quantities of water when needed	water not available from the source	60(75.9)	162(84.8)
	water too expensive	5(6.3)	4(2.1)
	source not accessible	14(17.7)	25(13.1)
Kind of drinking water storage containers	Narrow-mouthed	122(96.8)	249(98.8
Kind of drinking water storage containers	Both narrow and wide-mouthed	4(3.2)	3(1.2)
Cleaning of drinking water storage container	Daily	54(42.9)	73(29.0)
	Several times per week	17(13.5)	17(6.7)
	Once a week	55(43.7)	162(64.3)
Household-level drinking water treatment	Treat	11(8.7)	16(6.3)
Household-level drinking water treatment	Not treat	115(91.3)	236(93.7)

Eighty-one percent of households of cases and 75.4 % of households of controls used pit latrines with the slab/superstructure for defecation. Almost all of these latrines were not shared with other households in both cases and controls. Concerning places where under 5 children usually go to defecate, 49.2% cases and 46.4% control children’s defecated in the open field. Among the total households interviewed in this study, 42.9% of households in cases and 64.3% of households in controls disposed of their domestic solid waste by burning. Nineteen percent of cases and 9% of controls did not wash their hands at critical times (Table 3).

Table 3: Sanitation and hygiene practices of study participants of Kersa and Omo Nada districts in Jimma Zone, Ethiopia

Variables		Cases	Controls
Variables		No (%)	No (%)
Place of defecation	Pit latrine with slab	102(81.0)	190(75.4)
Place of defecation	Pit latrine without slab/open pit	24(19.0)	62(24.6)
Share the facility with another household	Yes	1(0.8)	9(3.6)
Share the facility with another household	No	125(99.2)	243(96.4)
Do all household members use the latrine?	Yes always	122(96.8)	247(98.0)
Do all household members use the latrine?	Yes sometime	4(3.2)	5(2.0)
Access and use of latrine at all times of the day and night by household members	Yes	107(84.9)	213(84.5)
	No	19(15.1)	39(15.5)
The main reason why household members were unable to access and use the latrine at all times of the day and night	Unable to use the toilet	5(26.3)	6(15.4)
	others	14(73.7)	33(84.6)
A place where under 5 children usually go to defecate	household/public latrine	13(10.3)	51(20.2)
	Open defecation	62(49.2)	117(46.4)
	others	51(40.5)	84(33.3)
If there are children under 5 who didn't use the latrine what is done with their feces?	Collected and disposed of in the latrine	125(99.2)	228(90.5)
	Collected and disposed of elsewhere	1(0.8)	24(9.5)
Households domestic waste disposal place	Household waste pit	45(35.7)	60(23.8)
	Open area	27(21.4)	30(11.9)
	Burned	54(42.9)	162(64.3)
Latrine most often used have handwashing facilities with soap	Yes, with soap and water	4(3.2)	6(2.4)
	Sometimes	44(34.9)	57(22.6)
	Take your soap and water	-	14(5.6)
	No	78(61.9)	175(69.4)
Hand washing at the critical time	Yes, Always	102(81.0)	229(90.9)
Hand washing at the critical time	Some times	24(19.0)	23(9.1)

Risk factors for childhood undernutrition

The multivariable analysis results of childhood undernutrition with water supply, sanitation, and hygiene intervention are presented in Table 4. Initiation of breastfeeding, the presence of diarrhea, wealth index, place of defecation, feces disposal sites for under 5 children, and handwashing at critical times had a statistically significant association with childhood undernutrition. After adjustment, no significant associations were found between the distance of drinking water sources, time is taken to get water, the amount of water they get, cleaning of drinking water storage containers, the usual defecation site of under 5 children and domestic waste disposal sites with childhood undernutrition.

There was evidence of a negative association between undernutrition and a lack of formal education of the mother/caregiver (AOR = 0.98; 95% CI: 0.53-1.82). There was also a negative association between undernutrition and using unprotected water sources for drinking (AOR=0.35; 95% CI: 0.05-2.32) cooking and washing (AOR=0.60; 95% CI: 0.18-2.08). The odds of undernutrition were increased by 1.59 among children who had delayed initiation of breastfeeding compared to those who started early breastfeeding and were entirely dependent on it (AOR=2.59; 95% CI: 1.08-6.18). Similarly, the level of undernutrition was higher in children who had diarrhea at least once in the past two weeks compared with those who did not have diarrhea (AOR = 9.34; 95% CI: 5.19-16.81).

Families who collected drinking water from a distance of less than/equal to one km were 4.55 times more likely to have malnourished children compared to those who collected from a distance of greater than one km (AOR=4.55; 95% CI: 0.92-22.56). The odds of having undernutrition decreased by 78% among children living in families who used narrow-mouthed drinking water storage compared to those who used both(AOR=0.22; 95% CI: 0.02-2.13).

Under-five children who defecated in the open field were 1.29 times more likely to be malnourished than children living in the household who defecated in latrines (AOR=1.29; 95% CI: 0.47-3.57). Households who disposed of their domestic waste in open places were found to have more malnourished children than those who disposed of waste in pits (AOR=1.05; 95% CI: 0.29-3.83). The odds of having childhood undernutrition were 2.52 times higher among children living with mothers who wash their hands sometimes at critical times (AOR=2.52; 95% CI: 1.10-5.75) compared to those who wash always (Table 4).

Table 4: Multivariable analysis of drinking water supply, sanitation, and hygiene intervention, and childhood undernutrition among study participants of Kersa and Omo Nada districts in Jimma Zone, Ethiopia

Variables		Cases No (%)	Controls No (%)	Crude OR (95% CI)	Adjusted OR (95% CI)
Number of under-five children in the households	1	77(61.1)	169(67.1)	1	1
Number of under-five children in the households	2	49(38.9)	83(32.9)	1.30(0.83-2.02)	1.13(0.62-2.06)
Educational status of the mother/caregiver of the child	No/lack of formal education	56(44.4)	98(38.9)	1.25(0.82-1.94)	0.98(0.53-1.82)
Educational status of the mother/caregiver of the child	Literate	70(55.6)	154(61.1)	1	1
Initiation of breastfeeding	Delayed (>1 hour of birth)	53(42.1)	41(16.3)	3.73(2.29-6.08)*	2.59(1.08-6.18)*
Initiation of breastfeeding	Early (within 1 hour of birth)	73(57.9)	211(83.7)	1	1
Child breastfeed (Months)	up to 24	92(73.0)	131(52.0)	1	1
	still now	22(17.5)	95(37.7)	0.33(0.19-0.56)*	0.35(0.18-0.71)*
	Others (<24)	12(9.5)	26(10.3)	0.66(0.62-1.37)	0.52(0.221-1.31)
Had diarrhea at least once in the past two week(s)	yes	92(73.0)	58(23.0)	9.05(5.54-14.78)*	9.34(5.19-16.81)*
Had diarrhea at least once in the past two week(s)	No	34(27.0)	194(77.0)	1	1
Wealth index	Poor	38(30.16)	89(35.32)	0.92(0.54-1.57)	2.57(1.09-6.07)*
	Medium	48(38.10)	77(30.56)	1.34(0.80-2.25)	1.67(0.76-3.68)
	Wealthiest	40(31.75)	86(34.13)	1	1
The main source of drinking-water	Protected sources	122(96.8)	223(92.5)	1	1
The main source of drinking-water	Unprotected sources	4(3.2)	19(7.5)	0.40(0.13-1.21)	0.35(0.05-2.32)
The main source of water used by households for cooking and washing	Protected sources	115(91.3)	214(84.9)	1	1
	Unprotected sources	11(8.7)	38(15.1)	0.54(0.67-1.09)	0.60(0.18-2.08)
The distance of drinking water sources (Km)	less than/equal to1	123(97.6)	232(92.1)	5.53(1.03-12.13)*	4.55(0.92-22.56)
The distance of drinking water sources (Km)	greater than 1	3(2.4)	20(7.9)	1	1
Time to take to go there, get water, and come back (minutes)	≤30	50(39.7)	130(51.6)	1	1
	>30	76(60.3)	122(48.4)	1.62(1.05-2.50)*	0.86(0.42-1.76)
Amount of water get sufficient	Sufficient	47(37.3)	61(24.2)	1	1
Amount of water get sufficient	Not sufficient	79(62.7)	191(75.8)	0.54(0.54-0.85)*	0.43(0.09-2.00)
Kind of drinking water storage containers	Narrow-mouthed	122(96.8)	249(98.8	0.37(0.08-1.67)	0.22(0.02-2.13)
Kind of drinking water storage containers	Both narrow and wide mouthed	4(3.2)	3(1.2)	1	1
Cleaning of drinking water storage container	Daily	54(42.9)	73(29.0)	1	1
	Several times per week	17(13.5)	17(6.7)	1.35(0.63-2.89)	1.97(0.49-7.00)
	Once a week	55(43.7)	162(64.3)	0.46(0.29-0.73)*	1.23(0.35-4.31)
Place of defecation	Pit latrine with slab	69(54.8)	188(74.6)	1	1
Place of defecation	Pit latrine without slab/open pit	57(45.2)	64(25.4)	2.43(1.55-3.81)*	2.49(1.17-5.30)*
A place where under 5 children usually go to defecate	Use latrine	13(10.3)	51(20.2)	1	1
	Open defecation	62(49.2)	117(46.4)	2.28(1.04-4.99)*	1.29(0.47-3.57)
	Other	51(40.5)	84(33.3)	2.54(1.13-5.69)*	0.73(0.16-3.34)
If there are children under 5 who didn't use the latrine what is done with their feces?	Collected and disposed of in the latrine	125(99.2)	228(90.5)	1	1
	Collected and disposed of elsewhere	1(0.8)	24(9.5)	0.08(0.01-0.57)*	0.08(0.01-0.75)*
Households domestic waste disposal place	Household waste pit	45(35.7)	60(23.8)	1	1
	Open area	27(21.4)	30(11.9)	1.20(0.63-2.29)	1.05(0.29-3.83)
	Burned	54(42.9)	162(64.3)	0.44(0.27-0.73)*	0.79(0.22-2.87)
Hand washing at the critical time	Yes, Always	102(81.0)	229(90.9)	1	1
Hand washing at the critical time	Some times	24(19.0)	23(9.1)	2.34(1.26-4.34)*	2.52(1.10-5.75)*

*Significance at p< 0.05.

Many factors affect the nutritional status of children in a developing country like Ethiopia. The present study aimed to examine the association of childhood undernutrition with household water supply, sanitation, and hygiene interventions in Kersa and Omo Nada districts in Jimma Zone, Ethiopia. In this study, we found evidence that the odds of having childhood undernutrition were significantly reduced among children who breastfeed during data collection and dispose of under-five children feces elsewhere properly. However, delayed initiation of breastfeeding, the presence of diarrhea, poor living conditions (indexed as poor), living with families who defecated in pit latrines without a slab or in open pits, and lack of handwashing practices at the critical times significantly increased the likelihood of childhood undernutrition.

There was a negative association between the educational level of mothers/caregivers and childhood undernutrition in the multivariable model. This study finding was inconsistent with studies done in Malaysia, India, and Ethiopia, which stated that mothers/caregivers' education has a definite and significant effect on the nutritional status of children^7,23,33. The possible reason could be that despite their they have a high educational level, they would not have better practical skills to keep the sanitation and hygiene of their children or have no better information to provide an adequate diet to keep the nutritional status of their children.

Consistent with previous studies conducted in Malaysia and Bangladesh^23,34, our study showed a strong association between childhood undernutrition and wealth status. In the poorest households, mothers might have inadequate access to socio-economic resources to meet the nutritional needs of their children.

In this study, having diarrhea among children was shown to be a significant predictor of childhood undernutrition. Our findings revealed that the presence of the preceding two weeks of childhood diarrhea and undernutrition were positively associated. This finding was consistent with a previous finding that showed that the presence of childhood diarrhea increased the risk of undernutrition^6,8. However, these results were inconsistent with the study report from Northwest Ethiopia ⁷. The inconsistency might be due to socio-economic differences between the study participants.

Collecting drinking water from improved sources was related to the reduction of water contamination by infectious agents that may be competing for the absorption of nutrients when ingested. However, a strangely positive association was observed between collecting water from protected sources and a child’s undernutrition. This was in sharp contradiction with other studies done in Ethiopia and Indonesia^35,36. This difference could be related to the re-contamination of water during transportation or the lack of household water treatment and safe storage practices ³⁷.

Collecting water from a distance of less than/equal to 1km sources was found to be a strong predictor of childhood undernutrition in this study. This finding indicates that the nearest sources they used might be unprotected water sources that expose them to fecal bacteria and intestinal worms, which in turn deteriorates the nutritional status of children by malabsorption. The findings were supported by other studies done in rural Ethiopia and Kenya ^35,38.

This analysis showed that there was an inverse association between household access to a toilet facility and childhood undernutrition. Our findings incline to confirm the results of other studies carried out in Ethiopia and other parts of the world ^23,35,39. Improper disposal of waste causes environmental contamination that can affect a child’s nutritional status via environmental enteric dysfunction (enteropathy). This might happen when children are repeatedly exposed to pathogenic bacteria that prevent the absorption of nutrients by damaging the intestinal mucosa ¹⁴. The findings of our study agreed with pooled evidence of a systematic review done on environmental risk factors associated with child stunting by Vilcins D, and others⁴⁰.

Regular hand washing at critical times was negatively associated with childhood undernutrition, which was in line with studies conducted in Bangladesh and Armenia, which revealed a significant inverse association between handwashing at critical times and childhood undernutrition^20,41. Another cluster randomized controlled trial study done in Pakistan proved that handwashing promotion can improve the nutritional status of children^20,41. Another cluster randomized controlled trial study done in Pakistan proved that handwashing promotion could improve the nutritional status of children⁴².

This study has some limitations. Variables such as data related to the nutrition and health status of mothers, the food security of households, and the type of diet children consumed that influenced the nutritional status of children were not fully assessed in the present study.

The findings of this study confirmed that the odds of developing undernutrition were significantly reduced among children who breastfeed during data collection and whose feces was properly disposed of. On the contrary, it was significantly increased among children with delayed initiation of breastfeeding. Having diarrhea, living in the poorest households, living with families who defecated in the pit latrine without slab and open pits, and lack of handwashing practices at critical times produced a higher risk of undernutrition. Therefore, the current study suggests that promoting the early initiation of exclusive breastfeeding, preventing diarrhea, the use of improved latrine, and handwashing at critical times are needed to improve the nutritional status of children. Additionally, WASH programmers and other NGOs working on child health should emphasize integrating nutrition with sanitation and hygiene programs to create awareness and induce communities’ behavior change.

Ethical considerations: The study was reviewed and ethical clearance was secured from Addis Ababa University, Ethiopian Institute of Water Resources. Because of the high proportion of illiteracy to read the consent form, informed verbal consent was obtained from mothers/caregivers after explaining the purpose of the study. Mothers/caregivers were assured of confidentiality concerning all information acquired. Children who were found with childhood undernutrition during visits, and those who did not start treatment, were linked to the health center after consultation.

Disclosure statement: The authors declare that they have no competing interests

Funding: This work was supported by Addis Ababa University, Ethiopian Institute of Water Resources. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

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Association of childhood undernutrition with water supply, sanitation and hygiene interventions in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: A case-control study

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