EFFECT OF WATER, SANITATION AND HYGIENE ALONE AND COMBINED WITH NUTRITION INTERVENTIONS ON CHILD GROWTH IN LOW-AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Tolesa Bekele^1,2, Bayzidur Rahman¹, Patrick Rawstorne¹

¹School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

²Department of Public Health, College of Medicine and Health Sciences, Ambo University, Oromia, Ethiopia

EFFECT OF WATER, SANITATION AND HYGIENE ALONE AND COMBINED WITH NUTRITION INTERVENTIONS ON CHILD GROWTH IN LOW-AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

Background: Literature offers contradictory findings about effect of water, sanitation and hygiene (WASH) interventions separately and when combined with nutrition on child growth outcomes. The aim of this paper is to review the available evidence.

Methods: PubMed, MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science, and Science Direct were searched in May 2018 and last updated in April 2019. The review was done for children under-5 years of age. We conducted study-level meta-analysis using PRISMA guidelines and used fixed and random effects models. Pooled effect estimate was performed in mean difference (MD) with 95% confidence interval. Heterogeneity was assessed using Cochrane Q-test and quantified by I² statistics.

Results: A total of 17 studies from low- and middle-income countries were included in this review; 12 were cluster randomized (RCTs) and 5 were none randomized (non-RCTs). There was an effect of WASH interventions alone on height-for-age (HAZ) growth from non-RCTs (MD = 0.14; 95% CI: 0.08 to 0.21), however, RCTs alone showed no effect on HAZ (MD = 0.01; 95% CI: -0.03 to 0.05). WASH interventions alone improved HAZ of a child for interventions that were provided over 18 to 60 months (MD = 0.05; 95% CI: 0.02 to 0.09). The subgroup analysis indicated that children in age <= 24 months showed a positive response to WASH interventions alone (MD = 0.07; 95% CI: 0.01 to 0.13). A significant improvement in HAZ was indicated by combined WASH with nutrition (MD = 0.12; 95% CI: 0.07 to 0.17). WASH interventions alone did not improve weight-for-age (WAZ), however, combined WASH with nutrition showed an effect on WAZ (MD= 0.08; 95% CI: 0.03 to 0.13). WASH interventions alone and combined with nutrition did not improve weight-for-height of a child.

Conclusion: WASH alone improved HAZ for interventions 18 to 60 months of provision and children < 2 years of age. Combined WASH with nutrition indicated strong effect on HAZ. Integrated WASH with nutrition interventions would be effective to tackle child growth failure with emphasize in the first 1000 days of a child’s life.