Childhood Undernutrition Mediates the Relationship Between Open Defecation with Anemia Among Ethiopian Children: a Nationally Representative Cross-sectional Study

Overview

Journal BMC Public Health

Publisher Biomed Central

Specialty Public Health

Date 2024 Jun 3

PMID 38831296

Authors

Biniyam Sahiledengle

Pammla Petrucka

Fikreab Desta

Yordanos Sintayehu

Telila Mesfin

Lillian Mwanri

Affiliations

Soon will be listed here.

Abstract

Background: Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia.

Methods: We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders.

Results: Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of β = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (βindirect = 0.014, p < 0.001), wasting (βindirect = 0.009, p = 0.002), and underweight (βindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of βtotal = 0.285, p < 0.001.

Conclusion: Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.

References

Iannotti L, Tielsch J, Black M, Black R . Iron supplementation in early childhood: health benefits and risks. Am J Clin Nutr. 2006; 84(6):1261-76. PMC: 3311916. DOI: 10.1093/ajcn/84.6.1261. View

Kuse K, Jima D, Chikako T, Hagan Jr J, Seidu A, Aboagye R . Individual, Maternal, Household, and Community Level Variability in Determining Inequalities in Childhood Anaemia within Ethiopia: Four-Level Multilevel Analysis Approach. Children (Basel). 2022; 9(9). PMC: 9497788. DOI: 10.3390/children9091415. View

Seboka B, Alene T, Ngusie H, Hailegebreal S, Yehualashet D, Gilano G . Spatial Variations and Determinants of Acute Malnutrition Among Under-Five Children in Ethiopia: Evidence from 2019 Ethiopian Demographic Health Survey. Ann Glob Health. 2021; 87(1):114. PMC: 8622002. DOI: 10.5334/aogh.3500. View

Belay D, Asratie M, Aragaw F, Tsega N, Endalew M, Gashaw M . Open defecation practice and its determinants among households in sub-Saharan Africa: pooled prevalence and multilevel analysis of 33 sub-Saharan Africa countries demographic and health survey. Trop Med Health. 2022; 50(1):28. PMC: 8962481. DOI: 10.1186/s41182-022-00416-5. View

Okullo J, Moturi W, Ogendi G . Open Defaecation and Its Effects on the Bacteriological Quality of Drinking Water Sources in Isiolo County, Kenya. Environ Health Insights. 2017; 11:1178630217735539. PMC: 5637965. DOI: 10.1177/1178630217735539. View

Chaparro C, Suchdev P . Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci. 2019; 1450(1):15-31. PMC: 6697587. DOI: 10.1111/nyas.14092. View

Vyas S, Kov P, Smets S, Spears D . Disease externalities and net nutrition: Evidence from changes in sanitation and child height in Cambodia, 2005-2010. Econ Hum Biol. 2016; 23:235-245. PMC: 5147726. DOI: 10.1016/j.ehb.2016.10.002. View

Tesfaw L, Woya A . Potential mediators of the link between wealth index and anthropometric indices of under-five children in Ethiopia. Front Public Health. 2022; 10:981484. PMC: 9606741. DOI: 10.3389/fpubh.2022.981484. View

Preacher K, Rucker D, Hayes A . Addressing Moderated Mediation Hypotheses: Theory, Methods, and Prescriptions. Multivariate Behav Res. 2016; 42(1):185-227. DOI: 10.1080/00273170701341316. View

10.

Larsen D, Grisham T, Slawsky E, Narine L . An individual-level meta-analysis assessing the impact of community-level sanitation access on child stunting, anemia, and diarrhea: Evidence from DHS and MICS surveys. PLoS Negl Trop Dis. 2017; 11(6):e0005591. PMC: 5464528. DOI: 10.1371/journal.pntd.0005591. View

11.

Pivina L, Semenova Y, Dosa M, Dauletyarova M, Bjorklund G . Iron Deficiency, Cognitive Functions, and Neurobehavioral Disorders in Children. J Mol Neurosci. 2019; 68(1):1-10. DOI: 10.1007/s12031-019-01276-1. View

12.

Chakrabarti S, Singh P, Bruckner T . Association of Poor Sanitation With Growth Measurements Among Children in India. JAMA Netw Open. 2020; 3(4):e202791. PMC: 7160693. DOI: 10.1001/jamanetworkopen.2020.2791. View

13.

Matangila J, Doua J, Linsuke S, Madinga J, Inocencio da Luz R, Van Geertruyden J . Malaria, schistosomiasis and soil transmitted helminth burden and their correlation with anemia in children attending primary schools in Kinshasa, Democratic Republic of Congo. PLoS One. 2014; 9(11):e110789. PMC: 4220949. DOI: 10.1371/journal.pone.0110789. View

14.

Wieringa F, Dahl M, Chamnan C, Poirot E, Kuong K, Sophonneary P . The High Prevalence of Anemia in Cambodian Children and Women Cannot Be Satisfactorily Explained by Nutritional Deficiencies or Hemoglobin Disorders. Nutrients. 2016; 8(6). PMC: 4924189. DOI: 10.3390/nu8060348. View

15.

Islam M, Rahman M, Unicomb L, Kafi M, Rahman M, Alam M . Child defecation and feces management practices in rural Bangladesh: Associations with fecal contamination, observed hand cleanliness and child diarrhea. PLoS One. 2020; 15(7):e0236163. PMC: 7371197. DOI: 10.1371/journal.pone.0236163. View

16.

Fancony C, Soares A, Lavinha J, Barros H, Brito M . Effectiveness of Nutrition and WASH/malaria educational community-based interventions in reducing anemia in children from Angola. Sci Rep. 2021; 11(1):5603. PMC: 7946872. DOI: 10.1038/s41598-021-85006-x. View

17.

Osumanu I, Kosoe E, Ategeeng F . Determinants of Open Defecation in the Wa Municipality of Ghana: Empirical Findings Highlighting Sociocultural and Economic Dynamics among Households. J Environ Public Health. 2019; 2019:3075840. PMC: 6378051. DOI: 10.1155/2019/3075840. View

18.

Asfaw M, Wondaferash M, Taha M, Dube L . Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia. BMC Public Health. 2015; 15:41. PMC: 4314803. DOI: 10.1186/s12889-015-1370-9. View

19.

Janmohamed A, Karakochuk C, Mclean J, Green T . Improved Sanitation Facilities are Associated with Higher Body Mass Index and Higher Hemoglobin Concentration Among Rural Cambodian Women in the First Trimester of Pregnancy. Am J Trop Med Hyg. 2016; 95(5):1211-1215. PMC: 5094240. DOI: 10.4269/ajtmh.16-0278. View

20.

Gebreegziabher T, Regassa N . Ethiopia's high childhood undernutrition explained: analysis of the prevalence and key correlates based on recent nationally representative data. Public Health Nutr. 2019; 22(11):2099-2109. PMC: 10260527. DOI: 10.1017/S1368980019000569. View