Improving sanitation and hygiene: effects on childhood growth in rural Zambia
Van Es, Katherine
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The relationships between water, sanitation, and hygiene (WASH) interventions and malnutrition markers such as stunting, wasting, and underweight have been poorly characterized until recently. There is a need to identify interventions that may play a role in these relationships to improve nutritional status of children under 5 years old. In 2013, Zambia was not on track to meet MDG 7c, to halve the proportion of the population without sustainable access to safe drinking water and basic sanitation. To address this goal, the Zambian government implemented the Zambia Sanitation and Hygiene Program (ZSHP). The goal of the program was to reduce WASH-related diseases in rural areas by promoting community wide sanitation using community-led total sanitation (CLTS), legal enforcement, and hygiene promotion. An important component of the ZSHP is CLTS, which has been implemented in a majority of districts. The overall study aims to explore the effectiveness of a CLTS intervention on coverage and quality of household sanitation facilities, defecation behavior, and child health in a rural setting in Zambia. A secondary outcome that was measured in the analysis of the overall study was the effect of CLTS on stunting, wasting, and underweight in children under the age of 5. These three outcomes are the focus of this thesis. It was hypothesized that these three outcomes would decrease in prevalence with an increase in sanitation coverage resulting from the CLTS program. Cross-sectional anthropometric and household data for Zambian children under 5 and their households from baseline and end line surveys were analyzed to determine any association between multiple WASH indicators and nutritional status. The baseline survey was conducted in 2013 and the end line in 2016. Only households with at least one child under the age of 5 were surveyed at both baseline and end line. Primary caretakers were interviewed during home visits to assess sanitation resources, child-feeding practices, and the health status of their children under the age of 5. In addition, anthropometric data of children under the age of 5 was taken to assess their nutritional status of their children. The prevalence of underweight, stunting, and wasting at end line was 12.9%, 40.9%, and 7.4% respectively, all of which showed statistically significant decreases from baseline measurements (p=≤0.001, 0.03, and ≤0.001 respectively). Predictors of undernutrition were analyzed using logistic regression controlling for age and sex. Nutritional status of children under 5 years of age was found to be associated with several WASH indicators. Children who were taken to a clinic during an episode of diarrhea and children who lived in households with an improved water source had 46% and 26%, respectively, decreased odds of being stunted. Children who lived in households that were close (<4 min walk) to a water source had a 73% decrease in odds of being wasted. Finally, children who had diarrhea in the two weeks before the survey had 63% and 42% increased odds of being underweight or wasted respectively. Focus areas of the program have increased coverage of key indicators of sanitation and hygiene but a relatively high prevalence of sanitation- and hygiene-related diseases remain. These rural areas have high rates of reported diarrhea, acute respiratory illness, and stunting among young children even though most have had exposure to the ZSHP activities. With increased focus, not only on better human sanitation, but also on household environment sanitation, the prevalence of disease and malnutrition will start to decrease and we will begin to see healthier communities in Zambia.