Background
Inadequate nutrition in early life and exposure to sanitation-related enteric pathogens have been linked to poor growth outcomes in children. Despite rapid development in Cambodia, high prevalence of growth faltering and stunting persist among children. This study aimed to assess nutrition and WASH variables and their association with nutritional status of children under 24 months in rural Cambodia.
Methods
We conducted surveys in 491 villages across 55 rural communes in Cambodia in September 2016 to measure associations between child, household, and community-level risk factors for stunting and length-for-age z-score (LAZ). A primary survey measured child-level variables, including anthropometric measures and risk factors for growth faltering and stunting, for 4,036 children under 24 months of age from 3,877 households (approximately 8 households per village). A secondary survey of 5,341 households, including the same households from the primary survey and an additional 1,464 households (approximately 3 additional household per village) from the same villages, assessed village-level WASH variables to understand community water, sanitation, and hygiene (WASH) conditions that may influence child growth outcomes. For LAZ, we calculated bivariate and adjusted associations (as mean differences) with 95% confidence intervals using generalized estimating equations (GEEs) to fit linear regression models with robust standard errors. For stunting, we calculated unadjusted and adjusted prevalence ratios (PRs) with 95% confidence intervals using GEEs to fit Poisson regression models with robust standard errors. For all models assessing effects of household-level variables, we used GEEs to account for clustering at the village level.
Findings
After adjustment for potential confounders, presence of water and soap at a household's handwashing station was found to be significantly associated (p<0.05) with increased LAZ (adjusted mean difference in LAZ +0.10, 95% CI 0.03 to 0.16), and household use of an improved drinking water source was associated with less stunting in children compared to households that did not use an improved source of drinking water (aPR 0.81, 95% CI 0.66 to 0.98); breastfeeding and community-level access to an improved drinking water source were associated with a lower LAZ score (-0.16, 95% CI -0.27 to -0.05; -0.13, 95% CI -0.26 to 0.00). No other nutrition (i.e., dietary diversity, meal frequency) or sanitation variables (i.e., household's safe disposal of child stools, household-level sanitation, community-level sanitation) were measured to be associated with LAZ scores or stunting in children under 24 months of age.
Understanding, Choosing, and Unifying Multilevel and Fixed Effect Approaches
