European Journal of Cardiovascular Medicine

Stunting, defined as impaired growth and development manifested by low height-for-age, is a critical public health issue affecting millions of children worldwide. It is a key indicator of chronic malnutrition and is associated with long-term consequences such as cognitive deficits, reduced educational attainment, and increased susceptibility to chronic diseases in adulthood. ^[1] According to the World Health Organization (WHO), stunting affects approximately 22% of children under five globally, with the highest burden observed in low- and middle-income countries (LMICs).^[2] In India, the prevalence of stunting remains alarmingly high, with the National Family Health Survey-5 (NFHS-5) reporting that 35.5% of children under five are stunted. This underscores the urgent need for targeted interventions to address the underlying causes of stunting. ^[3]

One of the primary determinants of stunting is poor Water, Sanitation, and Hygiene (WASH) practices. Inadequate access to clean water, improper sanitation facilities, and poor hygiene behaviors contribute significantly to the burden of diarrheal diseases and environmental enteropathy, both of which are critical pathways to malnutrition and stunting. ^[4] Diarrheal diseases, often caused by contaminated water and poor sanitation, lead to nutrient malabsorption and recurrent infections, which impair a child's growth. ^[5] Similarly, environmental

enteropathy, a subclinical condition caused by chronic exposure to fecal pathogens, results in intestinal  inflammation and reduced nutrient uptake, further exacerbating the risk of stunting. ^[6]

The association between WASH practices and stunting has been widely studied, with evidence suggesting that improved access to clean water, proper sanitation, and good hygiene practices can significantly reduce the prevalence of stunting. For instance, studies have shown that households with access to improved water sources and sanitation facilities have lower rates of stunting compared to those without such access. ^[7] Similarly, handwashing with soap at critical times, such as before eating and after defecation, has been shown to reduce the incidence of diarrheal diseases, thereby mitigating the risk of stunting. ^[8] Despite this evidence, the integration of WASH interventions into nutrition programs remains limited, particularly in resource-constrained settings like India. ^[9]

In India, the burden of stunting is compounded by the widespread prevalence of poor WASH practices. According to NFHS-5, only 58.6% of households have access to improved sanitation facilities, and 49.8% practice safe disposal of child feces. ^[10] Furthermore, handwashing with soap and water is practiced by only 60.6% of households, highlighting significant gaps in hygiene behaviors.

The study was conducted over 12 months in the outpatient department of pediatrics at a tertiary care hospital in India. Ethical approval was obtained from the Institutional Ethics Committee. A total of 230 children aged 6 months to five years and their caregivers participated. Data collection involved structured questionnaires on household water sources, sanitation facilities, hand hygiene practices, and caregiver knowledge of gastrointestinal diseases. Anthropometric measurements, including height and weight, were taken using standard procedures, and z-scores were calculated using WHO AnthroPlus software. Statistical analysis was conducted using SPSS version 22, with chi-square tests used to assess associations.

Stunting Prevalence

20% of the study population was stunted.

Hand Hygiene Practices

Caregivers using hand hygiene facilities had significantly lower rates of stunted children (p = 0.0001). Similarly, children who practiced hand hygiene had a lower prevalence of stunting.    

Sanitation Facilities

Use of sanitary toilets was associated with a reduced likelihood of stunting (p = 0.0001). 

Table 1: Demographic Characteristics of Study Population

Table 2: WASH Practices and Stunting Outcomes

This study aimed to evaluate the association between Water, Sanitation, and Hygiene (WASH) practices and stunting in children aged 6 months to five years. The findings provide significant insights into how different environmental and behavioral factors contribute to childhood malnutrition.

The study revealed that a notable proportion of children exhibited stunting (HAZ score < -2). Stunting is a major public health concern in India, often linked to chronic malnutrition, recurrent infections, and inadequate care practices. ^[11]

The results indicate a higher prevalence of stunting among children from households that rely on unimproved water sources, such as wells or surface water. However, the chi-square analysis did not show a statistically significant association between water sources and stunting (p > 0.05). This suggests that while access to clean water is essential for overall child health, other factors such as sanitation, hygiene, and dietary intake may play a more crucial role in determining nutritional outcomes. ^[12]

Children from households with unimproved sanitation facilities had a higher likelihood of stunting compared to those with improved sanitation. Poor sanitation increases exposure to enteric infections, leading to frequent diarrhea and malabsorption of essential nutrients. ^[13] The chi-square test showed a moderate association between sanitation and stunting, reinforcing the importance of investing in proper waste disposal and latrine facilities. ^[14]

Hand hygiene practices were significantly associated with stunting in our study. Children from households where caregivers followed poor hand hygiene practices had a higher prevalence of stunting. ^[15] This aligns with previous research indicating that handwashing with soap reduces the transmission of pathogens responsible for diarrheal diseases and intestinal infections, which contribute to poor growth outcomes. ^[16]

Caregiver knowledge about gastrointestinal diseases and hygiene practices was assessed to understand its influence on child health. Although children with caregivers who had inadequate knowledge exhibited a slightly higher prevalence of stunting, the association was not statistically significant. ^[17] This finding suggests that while knowledge is important, behavioral implementation and other environmental determinants also play a crucial role in improving child health outcomes.

Improving WASH practices is essential for reducing stunting and enhancing child growth. Public health interventions should focus on increasing access to clean water, promoting the use of sanitary toilets, and encouraging proper hand hygiene among both caregivers and children. Raising awareness about the relationship between hygiene and health is critical to achieving sustainable improvements in child development.

Ethics Approval and Consent to Participate

Ethical approval was obtained from the Institutional Ethics Committee. Informed verbal consent was obtained from caregivers.

List of Abbreviations

• WASH: Water, Sanitation, and Hygiene
• WHO: World Health Organization
• NFHS: National Family Health Survey

Conflicts of Interest

The authors declare no conflict of interest regarding the publication of this article.

Funding Statement         

The authors declare that this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ Contributions

Dr. SCT designed the study, collected data, and performed data analysis. 

Dr. VW supervised the study and provided critical feedback. 

Both authors contributed to writing the manuscript and approved the final version.

Acknowledgments

The authors thank the caregivers and children who participated in this study, as well as the hospital staff for

 their support

1. World Health Organization (WHO). Stunting in a nutshell [Internet]. Geneva: WHO; 2023 [cited 2024 Feb 28]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition
2. United Nations Children's Fund (UNICEF). The state of the world's children 2023: For every child, nutrition [Internet]. New York: UNICEF; 2023 [cited 2024 Feb 28]. Available from: https://www.unicef.org/reports/state-worlds-children-2023
3. Wolf J, Bartram J, Clasen T, Cumming O, Freeman MC, et al. Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries. Int J Hyg Environ Health. 2019;222(5):765-77. doi:10.1016/j.ijheh.2019.05.004.
4. Cumming O, Cairncross S. Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications. Matern Child Nutr. 2016;12(Suppl 1):91-105. doi:10.1111/mcn.12258.
5. Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, Morris SS, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol. 2008;37(4):816-30. doi:10.1093/ije/dyn099.
6. Humphrey JH. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet. 2009;374(9694):1032-5. doi:10.1016/S0140-6736(09)60950-8.
7. Fink G, Günther I, Hill K. The effect of water and sanitation on child health: Evidence from the demographic and health surveys 1986-2007. Int J Epidemiol. 2011;40(5):1196-204. doi:10.1093/ije/dyr102.
8. Spears D, Ghosh A, Cumming O. Open defecation and childhood stunting in India: An ecological analysis of new data from 112 districts. PLoS One. 2013;8(9):e73784. doi:10.1371/journal.pone.0073784.
9. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: A systematic review and meta-analysis. Lancet Infect Dis. 2005;5(1):42-52. doi:10.1016/S1473-3099(04)01253-8.
10. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51. doi:10.1016/S0140-6736(13)60937-X.
11. Günther I, Fink G. Water, sanitation, and children's health: Evidence from 172 DHS surveys. Environ Health Perspect. 2011;119(3):298-305. doi:10.1289/ehp.1002056.
12. Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, et al. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database Syst Rev. 2013;8:CD009382. doi:10.1002/14651858.CD009382.pub2.
13. Dearden KA, Schott W, Crookston BT, Humphries DL, Penny ME, Behrman JR. Children with access to improved sanitation but not improved water are at lower risk of stunting compared to children without access: A cohort study in Ethiopia, India, Peru, and Vietnam. BMC Public Health. 2017;17(1):110. doi:10.1186/s12889-017-4033-1.
14. Torlesse H, Cronin AA, Sebayang SK, Nandy R. Determinants of stunting in Indonesian children: Evidence from a cross-sectional survey indicate a prominent role for the water, sanitation, and hygiene sector in stunting reduction. BMC Public Health. 2016;16(1):669. doi:10.1186/s12889-016-3339-8.
15. Luby SP, Mendoza C, Keswick BH, Chiller TM, Hoekstra RM. Difficulties in bringing point-of-use water treatment to scale in rural Guatemala. Am J Trop Med Hyg. 2008;78(3):382-7. doi:10.4269/ajtmh.2008.78.382.
16. Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G, Stoltzfus RJ. Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: Making the links. Ann N Y Acad Sci. 2014;1308(1):118-28. doi:10.1111/nyas.12330.
17. Corsi DJ, Mejía-Guevara I, Subramanian SV. Risk factors for chronic undernutrition among children in India: Estimating relative importance, population attributable risk and fractions. Soc Sci Med. 2016;157:165-85. doi:10.1016/j.socscimed.2015.11.014.