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(JMP) Indicators for Water Supply, Sanitation and Hygiene and Their Association with Linear Growth in Children 6 to 23 Months in East Africa

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(JMP) Indicators for Water Supply, Sanitation and Hygiene and Their Association with Linear Growth in Children 6 to 23 Months in East Africa International Journal of Environmental Research and Public Health Article The WHO and UNICEF Joint Monitoring Programme (JMP) Indicators for Water Supply, Sanitation and Hygiene and Their Association with Linear Growth in Children 6 to 23 Months in East Africa Hasina Rakotomanana * , Joel J. Komakech, Christine N. Walters and Barbara J. Stoecker Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK 74078, USA; [email protected] (J.J.K.); [email protected] (C.N.W.); [email protected] (B.J.S.) * Correspondence: [email protected]; Tel.: +1-(405)-338-5898 Received: 7 August 2020; Accepted: 26 August 2020; Published: 28 August 2020 Abstract: The slow decrease in child stunting rates in East Africa warrants further research to identify the influence of contributing factors such as water, sanitation, and hygiene (WASH). This study investigated the association between child length and WASH conditions using the recently revised WHO and UNICEF (United Nations Children’s Fund) Joint Monitoring Programme (JMP) indicators. Data from households with infants and young children aged 6–23 months from the Demographic and Health Surveys in Burundi, Ethiopia, Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia were used. Associations for each country between WASH conditions and length-for-age z-scores (LAZ) were analyzed using linear regression. Stunting rates were high (>20%) reaching 45% in Burundi. At the time of the most recent Demographic and Health Survey (DHS), more than half of the households in most countries did not have basic or safely managed WASH indicators. Models predicted significantly higher LAZ for children living in households with safely managed drinking water compared to those living in households drinking from surface water in Kenya (β = 0.13, p < 0.01) and Tanzania (β = 0.08, p < 0.05) after adjustment with child, maternal, and household covariates. Children living in households with improved sanitation facilities not shared with other households were also taller than children living in households practicing open defecation in Ethiopia (β = 0.07, p < 0.01) and Tanzania (β = 0.08, p < 0.01) in the adjusted models. All countries need improved WASH conditions to reduce pathogen and helminth contamination. Targeting adherence to the highest JMP indicators would support efforts to reduce child stunting in East Africa. Keywords: water quality; sanitation; hygiene; stunting; East Africa 1. Introduction Poor growth during the first thousand days leads to negative consequences ranging from decreased immunity to reduced academic performance in adulthood if not corrected early [1]. During the past two decades, child undernutrition rates have declined considerably due to the prioritization of the nutrition agenda worldwide. More specifically, global stunting rates for children under five decreased from 32.6% to 22.2% between 2010 and 2017 [2]. However, the reduction in child stunting in sub-Saharan Africa remained slow from 46.1% in 1970 to 40% in 2010 compared to the global reduction rate of 25.1% [3]. Therefore, the persisting high rates of stunting continue to be a public health concern in sub-Saharan Africa. Stunting rates remain especially high in the East African region where 39% of the children under five were stunted based on data from 2010 to 2016 [4]. Int. J. Environ. Res. Public Health 2020, 17, 6262; doi:10.3390/ijerph17176262 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, x 2 of 15 healthInt. J. concern Environ. Res. in Publicsub-Saharan Health 2020 Africa, 17, 6262. Stunting rates remain especially high in the East African 2 region of 14 where 39% of the children under five were stunted based on data from 2010 to 2016 [4]. Identifying determinants and addressing constraints related to child stunting are crucial in Identifying determinants and addressing constraints related to child stunting are crucial in designing effective nutrition-specific and nutrition-sensitive interventions and policies needed for designing effective nutrition-specific and nutrition-sensitive interventions and policies needed for progress worldwide. Furthermore, the importance of the underlying factors of stunting may vary progress worldwide. Furthermore, the importance of the underlying factors of stunting may vary across countries and even across regions within a country [5]. Thus, further investigation of the across countries and even across regions within a country [5]. Thus, further investigation of the contributing factors to malnutrition, such as inadequate water, sanitation, and hygiene (WASH) contributing factors to malnutrition, such as inadequate water, sanitation, and hygiene (WASH) conditionsconditions and and their their role role in in child child growth growth faltering isis needed.needed. PoorPoor WASHWASH practices practices have have been been associatedassociated with with suboptimal child child growth growth in sub-Saharan in sub-Saharan populations populations and globally and [6globally–8]; and, improved[6–8]; and, improvedWASH conditions WASH conditions have been accompaniedhave been accompanied by better child anthropometricsby better child inanthropometrics several studies [ 6in,7 ,9several–12]. studiesFigure [6,7,9–12].1 summarizes Figure three 1 summarizes pathways suggested three pathways to explain suggested the role ofto unsafeexplain WASH the role in of child unsafe stunting. WASH in Repeatedchild stunting. episodes Repeated of diarrhea episodes and chronic of diarrhea helminth and infections chronic helminth can reduce infections nutrient absorptioncan reduce leading nutrient absorptionto undernutrition leading to [13 undernutrition,14]. Additionally, [13,14]. environmental Additionally, enteric environmental dysfunction (EED), enteric widespread dysfunction in areas(EED), widespreadwith poor in WASH areas indicators, with poor hasWASH been indicators, suggested has to cause been impairedsuggested linear to cause growth impaired in children linear [15 growth,16]. in Achildren pooled [15,16]. analysis A frompooled 140 analysis countries from reported 140 countries that open reported defecation that open explained defecation 54% ofexplained the height 54% of variationthe height in variation children underin children the age under of five the [9 ].age Thus, of five inadequate [9]. Thus, WASH inadequate practices WASH likely practices contribute likely to contributethe slow to reduction the slow in reduction child stunting in child rates stunting in sub-Saharan rates in Africa. sub-Saharan Africa. Unsafe source of Breast, water, food, utensils, toys drinking water Poor sanitation Play area Infants’ hands Unsafe child’s stool disposal Caregivers’ hands Poor hygiene Fecal contamination of environment WASH behaviors and facilities Fecal ingestion by infants Helminth infection Environmental Enteric Dysfunction Diarrhea Decreased intestinal Increased microbial surface area translocation Anorexia Decreased nutrient Decreased nutrient Nutrients redirected Inadequate diet absorption from growth absorption Socio-economic Child undernutrition factors FigureFigure 1. 1. Pathways linking linking water, water, sanitation, sanitation, and hygiene and (WASH)hygiene conditions (WASH) and conditions child undernutrition. and child undernutrition.Adapted from Adapted Humphrey from [15 ]Humphrey and Dangour [15] et and al. [Da17].ngour Solid et lines al. represent[17]. Solid primary lines represent pathways primary and pathwaysdotted lines and representdotted lines secondary represent pathways. secondary pathways. However, large cluster randomized trials recently reported no effect of individual or combined However, large cluster randomized trials recently reported no effect of individual or combined WASH interventions on linear growth in children under 5 years [18]. Moreover, compared to improved WASH interventions on linear growth in children under 5 years [18]. Moreover, compared to nutrition alone, there were no additional benefits of combining better WASH and nutrition on child improved nutrition alone, there were no additional benefits of combining better WASH and nutrition length. Because of the high levels of pathogens reported from the children’s hands and in the drinking on child length. Because of the high levels of pathogens reported from the children’s hands and in water, the low-cost and household-level WASH implemented in these studies may not have been thesu drinkingfficient to water, reduce the pathogen low-cost contamination and household- [18level,19]. TheseWASH results implemented suggest that in these more studies elaborate may and not havemore been specific sufficient WASH servicesto reduce may pathogen be needed contamination to limit pathogen [18,19]. transmission These fromresults poor suggest WASH practices.that more elaborateThe UNICEF and more and WHOspecific Joint WASH Monitoring services Programme may be needed for Water to limit Supply, pathogen Sanitation transmission and Hygiene from (JMP) poor WASHprovides practices. criteria The for UNICEF global standardized and WHO Joint WASH Moni indicatorstoring Programme [20]. The indicators for Water have Supply, been updatedSanitation andto Hygiene include more (JMP) detailed provides specifications, criteria for calledglobal “ladders”, standardized within WASH each category. indicators These [20]. indicators The indicators can havebe usedbeen toupdated monitor to progress include towards more detailed safe WASH specif conditionsications, andcalled inresearch “ladders”, analyses
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