Association of access to water, sanitation and handwashing facilities with undernutrition of children below 5 years of age in Bangladesh: evidence from two population-based, nationally representative surveys.

OBJECTIVE: To examine the association between household access to water, sanitation and handwashing (WaSH) facilities and child undernutrition in Bangladesh. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of children less than 5 years using data collected from the 2019 Multiple Indicator Cluster Survey (MICS) and the 2017-2018 Bangladesh Demographic and Health Survey (BDHS). OUTCOME MEASURES: Stunting, wasting and underweight, defined as a Z-score <-2 SD for height-for-age, weight-for-height and weight-for-age, respectively. We applied hierarchical multiple binary logistic regression models. RESULTS: Among 30 514 children 0-59 months, there was a high prevalence of child undernutrition (MICS: 28.0% stunted, 9.8% wasted, 22.6% underweight; BDHS: 30.8% stunted, 8.4% wasted, 21.7% underweight). Most children came from households lacking basic sanitation (MICS: 39.1%, BDHS: 55.3%) or handwashing facilities (MICS: 43.8%, BDHS: 62.6%). Children from households without access to WaSH facilities experienced the highest rates of undernutrition. Exposure-specific adjusted logistic regression models showed that a lack of access to improved water sources was associated with greater odds of wasting (MICS: adjusted OR (AOR) 1.36, 95% CI 1.00 to 1.85, p<0.05); basic sanitation facility with higher rates of stunting (MICS: 1.13, 1.04 to 1.23, p<0.01) and underweight (BDHS: 1.18, 1.02 to 1.37, p<0.05); and a lack of handwashing facilities with stunting (BDHS: 1.27, 1.10 to 1.48, p<0.01) and underweight (MICS: 1.10, 1.01 to 1.19, p<0.05). In fully adjusted models, no basic sanitation facility was associated with higher odds of stunting (MICS: AOR 1.12, 1.03 to 1.22, p<0.01) and a lack of handwashing facilities with higher odds of underweight (BDHS: AOR 1.30, 1.10 to 1.54, p<0.01;MICS: AOR 1.09, 1.01 to 1.19, p<0.05). CONCLUSION: These findings demonstrate a significant association between poor household WaSH facilities and high prevalence of child undernutrition. Improving WaSH may help reduce child undernutrition in Bangladesh.

Seasonal variation in the association between household food insecurity and child undernutrition in Bangladesh: Mediating role of child dietary diversity.

Household food insecurity (HFI) and child dietary diversity (CDD) are variable across seasons. We examined seasonal variation in HFI and child undernutrition association and tested how CDD mediates this association. We analyzed data for 26,353 children aged 6-59 months drawn from nationally representative cross-sectional Food Security and Nutrition Surveillance Project data collected during 2012-2014 in Bangladesh across three seasons annually: Post-Aman harvest (January-April); Monsoon (May-August); and Post-Aus harvest (September-December). Multivariable logistic regression analysis adjusted for individual, maternal, household and geographical characteristics reveals that children of food-insecure households were more likely than food-secure households to be stunted (adjusted odds ratio, AOR: 1.12; 95% confidence interval, CI: 1.02-1.23; p < 0.05), wasted (AOR: 1.21; 95% CI: 1.05-1.39; p < 0.01) and underweight (AOR: 1.16; 95% CI: 1.04-1.3; p < 0.01). CDD mediated 6.1% of the total effect of HFI on underweight. These findings varied across seasons. HFI was associated with greater odds of underweight during Monsoon (AOR: 1.32; 95% CI: 1.08-1.62; p < 0.01) and Post-Aus (AOR: 1.21; 95% CI: 1.06-1.37; p < 0.01) while wasting during Post-Aus (AOR: 1.65; 95% CI: 1.35-2.01; p < 0.001). CDD largely mediated the total effect of HFI on underweight during the Post-Aman in 2012-2014 (23.2%). CDD largely mediated the total effect of HFI on wasting (39.7%) during Post-Aman season in 2014 and on underweight (13.7%) during the same season in 2012. These findings demonstrate that HFI is seasonally associated with child undernutrition and mediated by CDD as well in Bangladesh and seasonality and diversity should be considered while designing appropriate population-level food-based interventions to resolve child undernutrition.