Abstract
ContextRecent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites.MethodsWe analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12–23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups.FindingsOf 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting.ConclusionsIn contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings.
Highlights
Ending malnutrition is a critical prerequisite for sustainable development
In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting
We aimed to study whether water quality improvements similar to those studied in the WASH Benefits trial could improve early childhood growth in a rural Indian population grappling with poor living conditions, high population density, and very high prevalences of open defecation, infectious diseases and malnutrition.[17,18,19]
Summary
Ending malnutrition is a critical prerequisite for sustainable development. Despite important global progress since the year 2000, undernutrition in early life remains implicated in nearly half of deaths among children under 5 globally, representing a loss of nearly 3 million child lives per year.[1, 2] Stunting (suboptimal linear growth, defined as Z-scores falling below 2 standard deviations (SD) from the length-for-age/height-for-age WHO Child Growth Standards median) is the most prevalent form of child malnutrition, affecting an estimated 150.8 million children under age 5 (22.2 percent) worldwide in 2017.[2, 3] Child undernutrition, especially stunting, is linked to poor health and developmental trajectories in early life, and lower educational attainment, shorter stature, higher risk of non-communicable diseases, and reduced earnings in adulthood.[1, 4, 5]In recent years, the attention of researchers and international development partners has been drawn to the role of environmental contamination as a possible structural barrier to healthy development for children living in conditions of poverty. Ending malnutrition is a critical prerequisite for sustainable development. Despite important global progress since the year 2000, undernutrition in early life remains implicated in nearly half of deaths among children under 5 globally, representing a loss of nearly 3 million child lives per year.[1, 2] Stunting (suboptimal linear growth, defined as Z-scores falling below 2 standard deviations (SD) from the length-for-age/height-for-age WHO Child Growth Standards median) is the most prevalent form of child malnutrition, affecting an estimated 150.8 million children under age 5 (22.2 percent) worldwide in 2017.[2, 3] Child undernutrition, especially stunting, is linked to poor health and developmental trajectories in early life, and lower educational attainment, shorter stature, higher risk of non-communicable diseases, and reduced earnings in adulthood.[1, 4, 5]. The UN Sustainable Development Goals (SDGs) include ambitious new targets to eliminate open defecation and achieve universal access to safely managed sanitation and drinking water services by 2030.[10]
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