Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: Results from the Soweto Baby WASH study

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-forage (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (/? = -2.24) and 6 months (/?=-0.96); a decrease in WAZ at 1 month (8=-1.21), 6 months (/?= -1.57), and 12 months (/3= -1.92); and finally, with WHZ scores at 12 months (/?= -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (/? = 0.53) and WAZ (0 = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained

Acute to Chronic Malnutrition: How Significant Water, Sanitation, and Hygiene Factors Change with Health Outcomes and Geographies in the Western Highlands of Guatemala

Adequate and appropriate water, sanitation, and hygiene (WaSH) infrastructure is important for reducing pathogen exposures in developing communities. To improve the ability of field practitioners in optimizing WaSH infrastructure within communities, models can provide insight into the complex interactions among WaSH infrastructure, health outcomes, and geographies. This study investigated the significant correlations between WaSH infrastructure variables and three different health outcomes (diarrhea, environmental enteric dysfunction, and stunting) over five geographic regions within Guatemala. Exploratory structural equation modeling was used to build WaSH models from U.S. Agency for International Development (USAID) 2012 Food for Peace Survey data (n = 2,103). The models were then tested using USAID 2013 Western Highlands Integrated Program survey data collected from the same regions (n = 4,633). Our results support that significant WaSH infrastructure variables vary widely over health outcome and geographic region. Improved sanitation had the highest prevalence of significance among all models. The floor transmission route for pathogens was identified as significant across all geographies for child stunting. Additionally, commonalities in potential pathogen transmission routes were identified among environmentally similar geographies. Practitioners and policy makers must account for the specific geography and health outcome to identify which set of WaSH infrastructure interventions are most appropriate at the correct scale

Limited Benefits and High Costs are Associated with Low Monetary Returns for Guatemalan Household Investment in Water, Sanitation, and Hygiene Technologies

The child stunting rate (low height-for-age) in Guatemala is the sixth worst in the world. Child stunting is correlated both with short and long-term economic costs. While technologies to improve water, sanitation and hygiene (WaSH) are effective at ameliorating child stunting, current household investment in WaSH technologies is constrained (i.e., self-supply). To understand this constraint, data on household spending priorities and barriers to investment in WaSH technologies must be assessed. We utilize primary data from our partner community in Totonicapán, Guatemala to populate a structural equation model and benefit-cost analysis assessing the association between household WaSH technologies and child height-for-age. To test regional variations, we scale-up our approach to examine four additional regions across western Guatemala. The results suggest there is limited monetary gain for households to invest in WaSH technologies. Among the communities and regions where higher returns on investment for households were identified, significant WaSH technologies were cumulatively low cost and simple to obtain and use. We encourage stakeholders supporting a self-supply model to evaluate that incremental improvements in WaSH technologies financed by the household do not impose large costs without sufficient benefits, facilitating healthy WaSH mobility (a household\u27s ability to improve their WaSH technology status)

Primary Factors Statistically Associated with Diarrheal Occurrences

To successfully prevent diarrheal pathogen transmission, a variety of causal pathways should be considered. This study utilized a suite of tools to identify primary factors associated with diarrheal occurrences in a set of communities in Para, Brazil that had received a biosand filter (BSF). First, existing Demographic and Health Survey data sets from the departments of Para and Amazonas, Brazil were analyzed using three statistical techniques, namely: Mahalanobis-Taguchi Strategy, canonical correlation analysis, and latent factor regression. Second, results of statistical analyses were combined with a literature review and field observations to locally adapt a previously validated structural equation model (SEM) originally developed for Quiche, Guatemala. Third, a randomized household survey was used to collect data - including water sources, sanitation facilities, hygiene practices, socioeconomic statuses, education levels, BSF maintenance, and diarrheal occurrences - in Para, Brazil and analyzed with the hypothesized SEM. Household education level had the largest significant negative effect size on diarrheal occurrence, while improved water source had the largest positive significant effect size on diarrheal occurrence. Maintenance of the BSF in the home had a negligible effect size on diarrheal occurrence. Complex associations observed in the SEM between diarrheal occurrence and a variety of causal pathways support the view that a multibarrier intervention is warranted

Improving Environmental Health Practice and Policy through Convergence Research: A Case Study of Linked Food-Water Systems Enhancing Child Health

Promoting access to safe drinking water or access to nutritious food, each independently contribute uniquely to positive gains in human health. Nexus analysis -- a systems-based approach to study interconnection and interdependence -- provides a framework to expose interactions and interventions in linked food-water systems. Interactions result in unintentional changes in efficacy or toxicity creating poorer-than-expected health outcomes while synergistic interventions targeting both water, sanitation, and hygiene as well as food security, nutrition, and safety yield greater-than-anticipated improvements in health and wellness. Herein, we describe a case study of linked food-water systems, where discovery, integration, application, and the scholarship of teaching and learning, collectively enhanced child health through convergence research - a transdisciplinary approach to solve a compelling and specific problem. The method integrates five techniques predominant in the field of health care, including: (1) community-based participatory research, (2) structured reviews, (3) mixed methods, (4) structural equation modeling, and (5) interprofessional education - at multiple study sites in east Africa, Guatemala, Brazil, and South Africa. The compelling problem explored is, the lack of an overarching framework to achieve improvements in interdisciplinary environmental health practice and policy, to ultimately solve specific problems such as, the eradication of childhood stunting. Results demonstrate that convergence research improves environmental health practice and policy by exposing insights to be measured, validated, and disseminated

Association of Aflatoxin Exposure and Height-For-Age among Young Children in Guatemala

Aflatoxin exposure has been proposed to affect child height-for-age. The following hypothesized associations were tested in Guatemala: (1) aflatoxin (B1, B2, G1, G2) exposure and environmental enteric dysfunction (EED) and child height-for-age z-score; and (2) aflatoxin exposures and subsequent symptoms of aflatoxins. Maize consumption data, health data, and samples of maize from households were collected from mothers and their children–under five–in October 2016 (n = 320) and February 2017 (n = 120). Maize samples were tested for aflatoxin levels and maize consumption data were used to compute an aflatoxin exposure level. Results suggest that there was a significant negative correlation between the putative aflatoxin exposure level and child height-for-age z-score (-0.073, p = 0.030), but not for EED. Furthermore, aflatoxin exposure was significantly correlated with aflatoxin symptoms only at the same time point (0.123, p = 0.026). These results support the potential need for engineered solutions to household aflatoxin transmission problems in rural communities of Guatemala

What Causes Childhood Stunting among Children of San Vicente, Guatemala: Employing Complimentary, System-Analysis Approaches

Guatemala has the sixth worst stunting rate with 48% of children under five years of age classified as stunted according to World Health Organization standards. This study utilizes two different yet complimentary system-analysis approaches to analyze correlations among environmental and demographic variables, environmental enteric dysfunction (EED), and child height-for-age (stunting metric) in Guatemala. Two descriptive models constructed around applicable environmental and demographic factors on child height-for-age and EED were analyzed using Network Analysis (NA) and Structural Equation Modeling (SEM). Data from two populations of children between the age of three months and five years were used. The first population (n = 2103) was drawn from the Food for Peace Baseline Survey conducted by the US Agency for International Development (USAID) in 2012, and the second population (n = 372) was drawn from an independent survey conducted by the San Vicente Health Center in 2016. The results from the NA of the height-for-age model confirmed pathogen exposure, nutrition, and prenatal health as important, and the results from the NA of the EED model confirmed water source, water treatment, and type of sanitation as important. The results from the SEM of the height-for-age model confirmed a statistically significant correlation among child height-for-age and child-mother interaction (-0.092, p = 0.076) while the SEM of the EED model confirmed the statistically significant correlation among EED and type of water treatment (-0.115, p = 0.013). Our approach supports important efforts to understand the complex set of factors associated with child stunting among communities sharing similarities with San Vicente

The Influence of Local Market and Household Factors on Aflatoxin Presence in Maize and Symptoms of its Exposure to Children in Guatemala

Recent evidence supports the hypothesis that aflatoxin exposure from maize can influence malnutrition rates among children. Therefore, in Guatemala we investigated two questions; which maize sources exposed households to higher risk of aflatoxin exposure symptoms and what the risk factors were for each maize source, pre- and post-maize harvest. Survey data and household maize samples were collected in October 2016 (pre-harvest) and February 2017 (post-harvest) in San Vicente, Guatemala. Structural equation modeling (SEM) and odds ratios were used to assess the data. The results suggested that households which purchased maize from the market had 3.64 higher odds of high levels of aflatoxin. The models identified that good market purchase habits were significant for market-based maize sources while improved post-harvest practices and improved types of maize storage were significant for subsistence-based maize sources. Cumulative results suggest multiple interventions may be effective but are dependent on time of year and source of maize

Rethinking water, sanitation, and hygiene for human growth and development.

Life history theory emphasises plasticity in developmental and biological programming where conditions in early life, lead to long-term consequences for health and wellbeing. Studies linking water, sanitation, and hygiene, nutrition, and child growth and development have emphasised the optimisation of linear growth as a key metric for the evaluation of intervention efficacy. Life history characteristics pertaining to human growth and phenotypic plasticity, suggest that different developmental outcomes in early childhood may be responsive to different stimuli at different ages. Energy utilisation by the human brain, from birth through childhood, accounts for a disproportionate percentage of the resting metabolic rate. Undernutrition in early life, and its relative resultant energy deficiency, may trigger adaptive physiological mechanisms prioritising brain growth at the expense of body growth. Emphasis placed on linear growth may have impeded the significance of WASH due to excluding aspects of child development beyond height/weight. We propose that incorporating evolutionary public health and life history theory perspectives, allows for the identification of age-appropriate biological outcomes and WASH indicators, while anticipating the timing and life-course suitability of the interventions being operationalised. Finally, integrating reflections regarding context allows for the development of transformative WASH interventions.Isaac Newton Trust/Wellcome Trust ISSF/University of Cambridge Joint Research Grants Scheme

Complex Associations between Environmental Factors and Child Growth: Novel Mixed-Methods Approach

Environmental risks associated with child growth are complex, and intervention effectiveness has been consistently poor. To improve effectiveness, proper intervention points inside the complex system must be identified. Integrating site-specific knowledge, machine learning, and statistical modeling offers a powerful approach to addressing this problem. In this study, a novel four-step method is employed to identify the key environmental factors to low child height-for-age in Guatemala. The four steps included (1) the development of a region-specific, ranked list of contributing factors to low child height-for-age via informal interviews and literature; (2) the application of a clustering method to a large regional data set; (3) the identification of the top six ranked variables shared between Step 1 and 2; and (4) the analysis of the clustered, regional data set in a multigroup path analysis incorporating the top six ranked variables, diarrheal prevalence, and child height-for-age. Results suggested that an increase in diarrheal prevalence was not consistently associated with a decrease in child height-for-age. Having soap for handwashing was significantly correlated with lower diarrhea and higher height-for-age. The effect was larger in the poorer population. Finally, disease in maize was significantly correlated with lower diarrhea. This method provided an approach to reducing, modeling, and ranking large numbers of environmental risk factors to child growth, identifying potential regional intervention points