The association of water supply, sanitation and hygiene interventions and childhood malnutrition in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: A case-control study

Background: Malnutrition is the widely known nutritional disorder and one of the leading causes of morbidity and mortality among children in developing countries like Ethiopia. About 50% of under-nutrition around the world is associated with infections caused by unsafe water, inadequate sanitation or insufficient hygiene. However, there are limited available data which associate water supply, sanitation and hygiene practices and childhood malnutrition in Ethiopia particularly in the study area. Therefore, the objective of this study was designed to examine the association of water supply, sanitation and hygiene interventions and childhood malnutrition. Methods: Case-control study design was conducted from December 2018 to January 2019 Kersa and Omo Nada districts of Jimma Zone, Southwest Ethiopia. Randomly 126 cases and 252 controls were selected from the malnourished children and normal children, respectively. A pretested, structured, interviewer-administered questionnaire was used. Bivariate and multivariable logistic regression analyses were used to identify the study variables associated with childhood malnutrition and to adjust for confounders. The crude and adjusted odds ratios with 95% confidence interval was calculated to assess the level of significance and reported for each confounding variable. Results: The results of this study showed that c hildren living with mothers/caregivers lack of formal education were found to have 57% times less likely developed malnourished, compared to those living with mother/caregiver who attended secondary and above (AOR = 0.57; 95% CI: 0.26-1.24). The odds of having malnutrition were increased 0.56-11.39), defecating in open pit(AOR=1.33; 95% CI: 0.62-2.83),under-five children open field defecation practices (AOR=1.17; 95% CI: 0.42-3.23) and lack of hand washing at critical times (AOR=2.38; 95% CI: 1.07-5.29) were positively associated with childhood malnutrition. Conclusion : We conclude that improvement in the initiation of breastfeeding within one hour, diarrhea prevention, use of improved latrine and hand washing at critical times is needed to improve the nutritional status of children.


Source population
All children from 6 to 59 months, living Kersa and Omo Nada districts with Z-score of weightfor-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 sourced population of cases; whereas all children from 6 to 59 months with Z-score of weight-for-height-2 to +2SD, weight-for-age -2 to +2SD, height-for-age -2 to +2SD, or MUAC above 12 cm or have no edema based on growth reference of WHO [24]were sourced population of controls.

Inclusion and exclusion criteria
All children aged 6-59 months that have malnutrition, and their mothers' resided as district member for a year were included in cases. Whereas all children 6-59 months of age and have no malnutrition and their mothers resided as a district member for a year were included for control.
Children whose mothers are seriously ill and could not communicate to give information were excluded from the study.

Sample size determination and sampling procedure
The sample size was determined using a formula for calculating double population proportion by assuming estimates of proportion of normal children (P2) as 43.8% (taking water sources as a major factor (14)), α at 95% confidence level (1.96), odd 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 (15)), power = 80% (0.84), the ratio of cases to controls is 1:2. The study considered a 10% non-response rate and the required sample size was computed mathematically as equation This implies that 117 cases and 234 controls were required. After adding 10% for non-response rate, the final samples were 128 for cases and 256 controls.
Five health centers, which have children's malnutrition treatment center, were selected purposely from the two selected districts. Then, three kebeles (the smallest administrative structure) (high, medium and low kebeles based on malnutrition case report) from each were selected and the census was conducted to identify the number of under-five children in the kebeles and their nutritional status. Then the cases were randomly selected from the malnourished children and controls were randomly selected from normal children.

Anthropometric measurement
Body weight, length/height, mid-upper arm circumference, presence of edema of the children were measured in a similar fashion with previously conducted research and based on the WHO references [2,24,25]. Weight and height of the children were measured by salter scale and measuring board instrument, respectively. The body weight of all children was measured without shoes to the nearest 0.1g whereas height/length of children was measured using a measuring board to the nearest 0.1 cm. Each measurement was done twice, and the mean of the two readings was recorded. Then, using the weight/height reference table, we interpret the anthropometric measurements through the weight-for-height, weight-for-age, height-for-age percentage or standard deviation score (Z-score). Thumb pressure was applied on 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. Based on the Z-score, edema and MUAC value recorded and the nutritional status of children was identified using cutoff points recommended by the World Health Organization [24].
Confirmed malnourished children were linked to the health center after consultation of the data collector.
Program for Water Supply, Sanitation, and Hygiene 2017 core questions on water, sanitation and hygiene for household surveys [26] and the similar instrument used by previous studies [2,18,19]. Some questions were revised to suit the context of the study by the principal investigator.
It consists of maternal and child characteristics, sources of water for domestic uses and distance from home, their water storage practices, and water treatment techniques known and/or used in their households and hygienic and sanitation practices by asking questions like the practice of hand washing with soap/any detergent at critical times (after defecation, before handling food/water, before feeding a child, after cleaning child stool), covering drinking water storage and clean water containers regularly before filling, habits of touch/ dipping fingers in water during collection, place of defecation, latrine utilization by all family members, disposal system of children feces and domestic waste. The wealth index was developed from assets and other housing characteristics. Hand washing at critical times was assessed by asking whether they washed their hands after defecation, before handling food/water, before feeding a child or after cleaning child stool. If they responded yes for all of these hand washing time, we said always hand washing at critical times or if at least one missed we said sometimes they washed their hands at critical times. Mothers/caregivers were asked the age of their children or assess on immunization card if present. If they didn't know the age or didn't have immunization card, data collectors were asked whether the child was born before or after known holidays. They were also asked about any occurrence of diarrhea and vaccine 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 interview of mothers. The questionnaire used for this data collection was prepared originally 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, necessary correction and modification of the instrument were made.
Mother's interview and anthropometric measurement 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, completeness of the collected questionnaires and any other amendments were followed and given by supervisors and principal investigator.

Data analyses
Data were entered, cleaned and checked for correctness using EpiData version 4.2 and then after exportation, all statistical analyses were carried out using the 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 households' asset ownership and housing characteristics using principal component analysis [27]. It was categorized in poor, middle and rich. A binary logistic regression model was used to assess whether water supply, sanitation, and hygiene practice are associated with childhood malnutrition. Bivariate analysis was used to identify the study variables associated with childhood malnutrition and to adjust for confounders multivariable logistic regression analyses were used. All variables that had a pvalue of 0.25 or less in bivariate analysis were included in the multivariable analysis. The crude and adjusted odds ratios (OR) with 95% confidence intervals for variables were computed and reported. For both analyses, a variable that had a p-value < 0.05 was considered as statistically significant.

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 ages of these children were 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 ages of mothers of cases were 28.6 (± 3.1) years and controls were 28.1(±2.9) years.
Forty four percent of cases and 38.9% controls of the respondents were mothers' no/lack of formal education. In this study, 30.16% of cases and 35.32% of controls belong to the poor wealth index, whereas 31.75% of cases and 34.13% of controls were from good wealthy status, relatively ( Table 1).
The main sources of drinking water of the households of 96.8% of cases and 92.5% of controls were from protected sources. With regard to the mean daily water consumption of study participants, 16.2(±27. 8) liters per capita per person for cases and 14.9 (±11.2) liters per capita per person 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 kilometer. Sixty three percent of cases and 75.8% of controls reported that the amount of collecting water as insufficient. 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% cases and 93.7% controls, there were no water treatment practices at the point of use (Table 2).
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 these latrines were not shared with other households in both cases and controls. Nineteen percent of cases and 9% of controls do not wash their hands at critical times (Table 3).

Risk factors of childhood malnutrition
Bivariate analysis of socio-demographic and childhood malnutrition was computed at a 95% confidence interval. In the analysis, variables like the initiation of breastfeeding, length of child breastfeed (months) and the presence of diarrhea in the past two weeks were significantly associated with childhood malnutrition. There was a positive association between childhood malnutrition and lack of formal education of mothers, large family size and under-five in the households. The odds of having childhood malnutrition were reduced by 8%among children live with mother's index as economically poor compared those mothers grouped as the wealthiest (COR= 0.92: 95% CI: 0.54-1.57). Initiation of breastfeeding after 1 hour of birth (COR=3.73: 95% CI: 2.29 -6.08) and presence of diarrhea (COR=9.05: 95% CI: 5.54-14.78) more likely increases the risk of childhood malnutrition (Table 1). Bivariate analysis of water supply and childhood malnutrition was also computed. Accordingly, distances of water sources, time to fetch water, the sufficiency of water they get and cleaning of drinking water storage container had a statistically significant association with childhood malnutrition in the binary analysis The odds of exposure to malnutrition among children live in households who collected drinking water from a distance of less than/equal to one kilometer was significantly higher than children live in households who collected water from a distance of greater than one kilometer (COR=5.53: 95% CI: 1.03-12.13). The likelihood of malnutrition was also increased if the time taken to water sources (time take to go there, get water, and come back) was greater than 30 minutes (COR=1.62: 95% CI: 1.05-2.50).But, the odds of having malnourished children were decreased by 46% when the water they get was not sufficient (COR=0.54: 95% CI: 0.54-0.85) ( Table 2).  The multivariable analysis results of childhood malnutrition with water supply, sanitation, and hygiene intervention are presented in Table 4. Initiation of breastfeeding, the presence of diarrhea, wealth index, place of defecation, under 5 children feces disposal sitesand hand washing at critical times were statistically significantly associated with childhood malnutrition.
After adjustment, no significant associations were found between the distance of drinking water sources, time taken to get water, amount of water they get, cleaning of drinking water storage container, under 5 children usually go to defecation place and domestic waste disposal sites with childhood malnutrition.
Children living with mother/caregiver lack of formal education were found to have 98% times less likely developed malnourished, compared to those living with secondary and above  Table 4).

Discussion
Many factors affecting the nutritional status of children in a developing country like Ethiopia. In the present study, our objective was designed to examine the association of the household water supply, sanitation and hygiene interventions and childhood malnutrition among children 6-59 months in Kersa and Omo Nada districts of Jimma Zone, Ethiopia. In this study, we found evidence that child breastfeed for less than 24 months and dispose of under-five children feces elsewhere were significantly reduced the odds of having childhood malnutrition. Whereas initiation of breastfeeding after one hour of birth, having diarrhea at least once in the past two weeks, poorest wealth status, living with families who defecting in a pit latrine without slab/open pit and lack of hand washing at critical time were significantly increased the likelihood of childhood malnutrition.
In our study finding, educational level of mothers/caregivers and childhood malnutrition were negatively associated in multivariable model. This study finding was inconsistent with studies done in Malaysia, India, and Ethiopia, which stated that mothers/caregivers education has definite and significant effect on nutritional status of children [19,28,29]. This might be due to the fact that even though they have a high educational level, they wouldn't have better practical skills to keep 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 other previously conducted studies in a different world [19,30], our study showed a strong association of childhood malnutrition and poorest wealth status. In poor 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 for childhood malnutrition. Our finding revealed that the presence of the preceding two weeks of childhood diarrhea and malnutrition was positively associated. The finding of this study was consistent with the previous finding that showed the presence of childhood diarrhea increased the risk of malnutrition [21,22]. But, inconsistent with the study report from Northwest Ethiopia [29]. This inconsistent might be due to the socio-economic difference of 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, we found that collecting water from protected (improved) sources was increased the odds of having childhood malnutrition. Studies reported in Ethiopia and Indonesia were contradicting our study finding [31,32]. The difference could be related re-contamination of water during transportation or lack household water treatment and safe storage practices [33].
In our study, collecting water from a distance of less than/equal to one kilometer water sources was found to be a strong predictor of childhood malnutrition. This implies 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.
This study was supported by other studies done in rural Ethiopia and Kenya [31,34] This analysis shows there was the inverse association between household access to a toilet facility and childhood malnutrition. Our study finding incline to confirm the findings of other studies carried out in Ethiopia and other parts of the world [19,31,35]. 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 absorption of nutrients by damaging the intestinal mucosa [10]. Our study also supports this evidence in such a way that improper disposal of household domestic waste was the risk factor for childhood malnutrition. Our study finding was agreed with pooled evidence of a systematic review done on environmental risk factors associated with child stunting by Vilcins D, and others [36].
A proper hand washing with soap at critical times is an effective means of reducing pathogen transmission. The present study also found that always hand washing at critical times was negatively associated with childhood malnutrition. These findings were in line with studies conducted in Bangladesh and Armenia that revealed significant association of hand washing at critical times and childhood malnutrition [16,37]. Another cluster randomized controlled trial study done in Pakistan proved that hand washing promotion could improve the nutritional status of the children [38].
The limitation of this study was data related to nutrition and health status of mothers, the food security of households and type of dietary children consumed were not included in this study.

Conclusions
The finding of this study confirmed that child breastfeed for less than 24 months and disposal of under-five children feces elsewhere were significantly reduced the odds of having malnutrition.
Whereas initiation of breastfeeding after one hour of birth, having diarrhea at least once in the past two weeks, poorest wealth status, living with families who defecting in pit latrine without slab/open pit and lack of hand washing at critical time were significantly increased the likelihood of childhood malnutrition. This study finding suggested that promoting in the initiation of breastfeeding within one hour, preventing diarrhea, use of improved latrine and hand washing at critical times are needed to improve the nutritional status of children. WASH programmers and other NGOs working on child health should also be given emphasis to integrate nutrition with sanitation and hygiene program for awareness creation and community behavior change.