Water, sanitation, and hygiene as a priority intervention for stunting in under-five children in northwest Ethiopia: a community-based cross-sectional study

Stunting is long-lasting malnutrition that happens when kids fail to achieve their linear growth potential. It results in irreversible cognitive and physical damage. A child is ‘stunted’ if the height of the child is less than minus two standard deviations(− 2 SD) of the WHO standard [1]. The process of becoming stunted typically begins in utero, though a child may not be classified as ‘stunted’ before 2 to 3 years of age [2].

Globally, an estimated 21.9% or 149 million (81.7 million in Asia and 58.8 million in Africa) under-five children were affected. It indicates that one in every four was stunted. In East Africa, 24 million children were stunted in 2018 [3]. The intervention did on intrauterine growth restriction, stunting, and severe wasting reduces the number of global deaths and disability-adjusted life years (DALYs) in under-five children [4]. It was reported that stunted children are more to drop out of school and take an extra 1.5 years to achieve and complete their education. Of all school year repetitions, 18% are associated with stunting [5].

Growth failure arises from complex environmental, social, and biological causes that are interlinked at various levels [6]. Denial of safe WASH access is an essential cause of maternal and child health and nutrition problems. The effect was magnificent during the first 1000 days of a child’s life from conception to 2 years of age. Five or more episodes of diarrhea during the 2 years of age contribute to a quarter of stunting in children globally [7]. In 2016, the prevalence of stunting in Ethiopia was 38%. In Amhara regional state the prevalence of stunting was also 46% [8]. WASH is the basic cause of stunting. Poor sanitation alone was the second leading cause worldwide [9]. Globally, 2.2 billion (one in three) people lack safe drinking water. Similarly, 4.2 billion people (3 in 5) population lack safe sanitation and about 673 million people around the world still practice open defecation. Also, 3 billion (2 out of 5) people around the world lack basic handwashing facilities. In Ethiopia, the proportion of the population practicing open defecation was 33%. About 90% of people live in communities where one household practices open defecation. There are also significant inequalities in water service levels between urban and rural populations. For instance, in Ethiopia, there is a 67% gap between rural (5%) and urban (72%) [10].

Poor Sanitation and unsafe drinking water cause diarrheal disease and environmental enteropathy. These inhibit nutrient absorption in the small intestine, which can lead to undernutrition and stunting. WASH interventions can prevent 860,000 Child deaths from undernutrition a year globally [7] and decreased stunting prevalence by 12% in Ethiopia [11].

The long-term effects of stunting on humans are poor cognitive development, school achievement, and economic productivity. Because of its magnitude and overwhelming consequences stunting gets the focus of international attention to reduce by 40% by 2025. With the current trends by 2025, about 127 million under-five children will be stunted. Investment and action are necessary to meet the 2025 World Health Assembly (WHA) target of reducing stunting to 100 million [12].

The government of Ethiopia was implementing WASH to combat malnutrition by organizing as part of the National Nutrition Programme II [13] and ONE WASH national program [14]. To come up and meet this target, many studies have been done to determine the magnitude and associated factors. Despite there were studies that show the linkages of nutrition and stunting, there is a paucity of evidence on environmental factors particularly WASH and stunting. Therefore, this study aimed to determine the prevalence of stunting and association between stunting and WASH factors that were understudied in Ethiopia.

In this community-based cross-sectional study, we estimated the prevalence of stunting and its associated factors in children under five. Our result showed that the prevalence of stunting in under-five children was 35.6% with 95%CI (31.9–39.5%). From all (224) stunted children, the magnitude of stunting doesn’t have a major difference between males and females.

The finding also revealed that under-five children with illiterate fathers and mothers, giving birth before marriage (single marital status), a big family size (> 5), short (< 150 cm) mother, unimproved drinking water source, unimproved sanitation status of the household, the poor hygienic practice of the household, diarrhea episodes in the previous 2 weeks before data collection, method of feeding children, age at introduction of complementary feeding started, less frequently feeding per day, lack of deworming treatment and mothers who had ANC visit of fewer than three times were at a higher odds of stunting.

The prevalence of stunting in this study was almost similar to the national prevalence (38%) of Ethiopia reported by the Ethiopian demographic and health survey (EDHS) 2016, but low as compared to the Amhara national regional state prevalence (46%) [8]. This discrepancy may be due to study time differences. Also, this prevalence was lower than the 2014 prevalence (50.7%) of Ethiopia [27]. A similar study in rural areas of Ethiopia indicates that the prevalence of stunting was 47.5% [28] which was higher than our findings. This difference may be due to study setting, environmental factors, the basic infrastructure of study households, socio-demographic characteristics of children’s parents, and study period.

However, the finding was higher than the prevalence of stunting in Aykel Town which was (28.4%) [29]. This difference may be due to the study subjects’ age category differences and other socio-demographic characteristics. Again the prevalence in this study was consistent with the findings of similar studies in Albuko district, south Wollo Ethiopia (39.3%) [30], in Hossana Town, Southern Ethiopia (35.4%) [31], and Shey Bench district southwest of Ethiopia, (33.3%) [32]. This similarity may be due to the similarity in the study setting and socio-demographic characteristics of study subjects.

In contrast to our study, the sex of the child was a predictor of growth failure in a similar study conducted in Lalibela and West Gojam Zone [33, 34]. In our finding, children whose mothers had no education were at greater risk of becoming stunted and consistent with findings in Hossana, and in 35 Low- and Middle-Income Countries [35, 36]. Another study from the 2014 Zambia demographic and health survey data revealed that children whose mothers had higher education showed 0.25 times less likely to be stunted as compared to children whose mothers had no education [37]. Similarly, paternal education was also a significant predictor of stunting in under-five children which is in line with a result in a systematic review conducted in East Africa [38]. Besides this, the marital status of mothers was also a significant factor in stunting. Children who were born to single mothers before marriage were 2.717 times more likely to become stunted as compared to the others.

In this study, stunting was associated with big family size (> 5). This finding was consistent with the finding from a study conducted in the rural community of Humbo district, Southern Ethiopia [39]. The result also showed that short mother (< 150 cm) was one of the significant factors associated with child stunting which is in line with a finding from a cross-sectional study in 35 Low- and Middle-Income Countries [36]. Another study conducted in Mekelle City, Tigray Region, north Ethiopia also indicates a consistent finding [40].

In our study stunting was associated with unimproved drinking water sources. It was consistent with a finding from a systematic review [38] and a study in Tehuledere District, North-East Ethiopia [17]. However, analysis from surveys in rural India, household access to improved water supply, or piped water was not associated with stunting [41]. An unimproved sanitation facility was significantly associated with stunting in this study. Consistent with our finding, stunting was associated with having no latrine facility [17], and households’ access to toilet facilities was associated with reduced odds of stunting among children in rural India [41]. Another finding from the analysis of Rwanda Demographic and Health Survey 2014/2015 also indicates that the sharing of a toilet was significantly associated with stunting [42].

The poor hygienic practices of households in this study were significantly associated with stunting. However, caregiver’s self-reported practices of handwashing with soap before meals or after defecation were inversely associated in rural India [41]. This may be due to the reporting bias of respondents. But, in our case; the data was collected by direct observation of the presence of a handwashing facility and soap. This study also revealed that stunting was not associated with field disposal of wastes. This finding was contradicting the finding from a study conducted in the rural community of Humbo district, Southern Ethiopia [39].

The literature review also indicated that the combined WASH intervention increased height-for-age Z scores and decreased the risk of stunting by 13% [43]. A result from meta-analysis revealed that WASH interventions were significantly associated with increased pooled mean height-for-age-z- score. This means that children who received combined WASH interventions reduced in growth retardation compared with children who received single interventions [44]. Another operational research project in Ethiopia also indicates that WASH intervention shows a significant increase in mean height-for-age Z-score and a 12.1% decrease in stunting prevalence [11].

Again, finding from our study revealed that stunting was associated with episodes of diarrhea. This was consistent with a finding from Gojam and Mekelle city, Ethiopia [33, 40]. The result was also consistent with a finding in Kersa district, Eastern Ethiopia [45]. In our study deworming status was a significant predictor of stunting which is consistent with a finding in Lalibela town [34]. Results from this study indicate that ANC visits less than three times were significantly associated with stunting. This finding was consistent with a finding from the analysis of Rwanda Demographic and Health Survey 2014/2015 [42].

In our study, the age of introduction of complementary feeding and method of feeding was significantly associated with stunting. This finding was similar to the study finding in West Gojam Zone Ethiopia [33]. Similarly, in a study conducted at Shey bench district, children who had started complementary feeding at less than 6 months or above 6 months were 3.78 times more likely to be affected by stunting than those who started complementary feeding at the age of 6 months [32]. Method of feeding children was affecting children for stunting in which those children who feed by bottle were less likely to become stunted. In addition, the frequency of feeding per day was also a significant predictor of stunting in under-five children.

In this study, stunting was a major public health problem in children under five. The magnitude was almost the same as national averages, and it requires greater attention. The factors significantly associated with stunting were illiteracy of father and mothers, giving birth before marriage, family size greater than five, short (< 150 cm) mother, unimproved drinking water source, unimproved sanitation, poor hygienic practice, having diarrhea in the previous 2 weeks before data collection period, method of feeding, frequency of feeding, age at which complementary feeding started, not dewormed and mothers who hand ANC visit of (< 3) times. Family planning utilization, maternal and paternal education, Water, Sanitation, and Hygiene (WASH) interventions in all areas of Ethiopia are critical to reducing the level of stunting among under-five children.