title: Household sanitation and personal hygiene practices are associated with child stunting in rural India: a cross-sectional analysis of surveys.
abstract: OBJECTIVE
  Increasing evidence suggests that water, sanitation and hygiene (WASH) practices affect linear growth in early childhood. We determined the association between household access to water, sanitation and personal hygiene practices with stunting among children aged 0-23 months in rural India.
  
  
  METHODS
  India.
  
  
  METHODS
  A total of 10 364, 34 639 and 1282 under-2s who participated in the 2005-2006 National Family Health Survey (NFHS-3), the 2011 Hunger and Malnutrition Survey (HUNGaMA) and the 2012 Comprehensive Nutrition Survey in Maharashtra (CNSM), respectively, were included in the analysis.
  
  
  METHODS
  The association between WASH indicators and child stunting was assessed using logistic regression models.
  
  
  RESULTS
  The prevalence of stunting ranged from 25% to 50% across the three studies. Compared with open defecation, household access to toilet facility was associated with a 16-39% reduced odds of stunting among children aged 0-23 months, after adjusting for all potential confounders (NHFS-3 (OR=0.84, 95% CI 0.71 to 0.99); HUNGaMA (OR=0.84, 95% CI 0.78 to 0.91); CNSM (OR=0.61, 95% CI 0.44 to 0.85)). Household access to improved water supply or piped water was not in itself associated with stunting. The caregiver's self-reported practices of washing hands with soap before meals (OR=0.85, 95% CI 0.76 to 0.94) or after defecation (OR=0.86, 95% CI 0.80 to 0.93) were inversely associated with child stunting. However, the inverse association between reported personal hygiene practices and stunting was stronger among households with access to toilet facility or piped water (all interaction terms, p<0.05).
  
  
  CONCLUSIONS
  Improved conditions of sanitation and hygiene practices are associated with reduced prevalence of stunting in rural India. Policies and programming aiming to address child stunting should encompass WASH interventions, thus shifting the emphasis from nutrition-specific to nutrition-sensitive programming. Future randomised trials are warranted to validate the causal association.
authors: Child Development and Nutrition Programme, United Nations Children's Fund, New Delhi, India.
authors: Jee Hyun
authors: JH
authors: Rah
authors: Water, Sanitation and Hygiene Programme, United Nations Children's Fund, Jakarta, Indonesia.
authors: Aidan A
authors: AA
authors: Cronin
authors: Child Development and Nutrition Programme, United Nations Children's Fund, New Delhi, India.
authors: Bhupendra
authors: B
authors: Badgaiyan
authors: Regional Office for South Asia, United Nations Children's Fund, Kathmandu, Nepal.
authors: Victor M
authors: VM
authors: Aguayo
authors: Water, Sanitation and Hygiene Programme, United Nations Children's Fund, New Delhi, India.
authors: Suzanne
authors: S
authors: Coates
authors: International Development Research Centre, New Delhi, India.
authors: Sarah
authors: S
authors: Ahmed
mesh_terms: D001827:Body Height; D002648:Child; D003430:Cross-Sectional Studies; D003625:Data Collection; D003672:Defecation; D005191:Family Characteristics; D005260:Female; D006130:Growth Disorders / Q000209:etiology*; D006235:Hand Disinfection; D006801:Humans; D006920:Hygiene; D007194:India; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D062407:Meals; D009752:Nutritional Status; D016017:Odds Ratio; D012424:Rural Population; D012499:Sanitation; D012915:Soaps; D014038:Toilet Facilities; D014881:Water Supply
chemical_list: D012915:Soaps
keywords: Stunting; Water and Sanitation