Abstract
Progress in health has occurred in the past decades in Cambodia, in terms of health service access and interventions, but several indicators, including the prevalence of malnourished children, remain alarming. The causes of undernutrition are often linked to inadequate access to water, sanitation and hygiene services but limited evidence exists on the direct association between poor WASH practices and children’s’ nutritional statuses. This study investigates the relationship between water, sanitation and hygiene practices, defined as the child-sensitive composite score, and the nutritional status of children under five years old, measured as the weight-for-height z-score, mid-upper arm circumference or height-for-age z-score in six districts of Cambodia. The analysis used data from a longitudinal study, comprising extensive data collection on anthropometry, health, nutrition, WASH, and cognitive development. Chronological trends in wasting and stunting were described cross-sectionally, whereas the effect of WASH practices on the nutritional status of children over up to three consecutive study visits was examined with a linear mixed-effects model. The prevalence of wasting decreased during the study while stunting prevalence increased. A small, but significant, association was found between the WASH child-sensitive composite scores and the wasting child anthropometry indicators: weight-for-height z-score or mid-upper arm circumference. Evidence for an association with height-for-age z-score, detecting stunted children, was found when the independent variable was quantified according to global, but not national, guidelines. This study reinforces discordant existing evidence towards a direct association between WASH practices and children’s nutritional status, suggesting the need to align nutrition and WASH programmes.
Highlights
Despite progress over the past two decades, global child undernutrition rates remain alarmingly high, in South Asia and in Sub-Saharan Africa
In this paper we aim to investigate for the first time in Cambodia the longitudinal association between water, sanitation and hygiene practices, regrouped as child-sensitive WASH composite scores, and the nutritional status of children under five years of age measured as weight-for-age z-score (WHZ) and mid-upper arm circumference (MUAC) for wasting and height-for-age z-score (HAZ) for stunting
/or MUAC < 125 mm) wasting prevalence decreased from 20% (649/3241) at baseline to 12.3%
Summary
Despite progress over the past two decades, global child undernutrition rates remain alarmingly high, in South Asia and in Sub-Saharan Africa. Stunting and wasting represent the predominant forms of undernutrition: stunting, a height for age two standard deviations below the mean, associated with chronic malnutrition, was globally estimated to affect 151 million children under five years old in 2017; wasting or acute malnutrition, defined as either a weight for height two standard deviations below the mean or a mid-upper arm circumference less than 125 mm, affected 51 million. Health Survey estimated the overall prevalence of undernutrition among children aged 0–59 months to be 32.4% for stunting and 9.8% for wasting. There were disparities between urban and rural provinces: 33.8% of rural children were stunted and 7.5% were wasted compared with 23.7% and 9.9%. By province, stunting prevalence was higher in Ratanakiri/Mondolkiri (39.8%) and Kratie (38.4%) than Phnom Penh (17.9%) while wasting prevalence was 8.4% in Phnom. Immediate causes include inadequate dietary intake and diseases; indirect factors comprise poverty, feeding and care practices, poor access to and low-quality health services and sociocultural, economic and political context [8] and are often liked to inadequate access to water, sanitation and hygiene (WASH)
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