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Improved water, hygiene, and sanitation practices

Nutrition-sensitive interventions

Overall impact:     Limited

Impact: 

  Mixed

Strength: 

  Limited
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Improved hygiene and sanitation practices lower the risk of diarrheal disease. In Peru, mothers were educated on hand washing through CRED.

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Literature Review

Impact: 

  Mixed

Strength: 

  Strong

 

Eight studies that evaluated the impact of infection and diarrhea on child HAZ in Peru and found an association between infection and/or diarrhea and HAZ. Diarrhea, enteroaggregative E. coli, STH, and early infancy Helicobacter pylori infection were associated with shorter child stature in Peru in other analyses, while Giardia was not.

1
Checkley W, Epstein LD, Gilman RH, Cabrera L, Black RE. Effects of acute diarrhea on linear growth in Peruvian children. Am J Epidemiol [Internet]. 2003;157:166-75.
2
Lee GO, Paredes Olortegui M, Salmón-Mulanovich G, Peñataro Yori P, Kosek M. Early child health in an informal settlement in the Peruvian Amazon. BMC Int Health Hum Rights [Internet]. 2016;16:1-9.
 
3
Lee G, Yori P, Olortegui MP, Pan W, Caulfield L, Gilman RH, Sanders JW, Delgado HS, Kosek M. Comparative effects of vivax malaria, fever and diarrhoea on child growth. Int J Epidemiol [Internet]. 2012;41:531-9.
 
4
Acosta GJ, Vigo NI, Durand D, Riveros M, Arango S, Zambruni M, Ochoa TJ. Diarrheagenic Escherichia coli: prevalence and pathotype distribution in children from Peruvian rural communities. Am J Trop Med Hyg [Internet]. 2016;95:574-9.
 
5
Jaganath D, Saito M, Gilman RH, Queiroz DMM, Rocha GA, Cama V, Cabrera L, Kelleher D, Windle HJ, Crabtree JE, et al. First Detected Helicobacter pylori Infection in Infancy Modifies the Association Between Diarrheal Disease and Childhood Growth in Peru. Helicobacter [Internet]. 2014;19:272-9.
 
6
Passaro DJ, Taylor DN, Gilman RH, Cabrera L, Parsonnet J. Growth slowing after acute Helicobacter pylori infection is age-dependent. J Pediatr Gastroenterol Nutr [Internet]. 2002;35:522-6.
 
7
Joseph SA, Casapia M, Montresor A, Rahme E, Ward BJ, Marquis GS, Pezo L, Blouin B, Maheu-Giroux M, Gyorkos TW. The Effect of Deworming on Growth in One-Year-Old Children Living in a Soil-Transmitted Helminth-Endemic Area of Peru: A Randomized Controlled Trial.[Erratum appears in PLoS Negl Trop Dis. 2015 Dec;9(12):e0004288; PMID: 26636967]. PLoS Neglected Trop Dis [electronic Resour [Internet]. 2015;9:e0004020.

One study, however, found no association.

8
Hollm-Delgado M, Gilman RH, Bern C, Cabrera L, Sterling CR, Black RE, Checkley W. Lack of an adverse effect of Giardia intestinalis infection on the health of Peruvian children. Am J Epidemiol [Internet]. Oxford University Press / USA; 2008;168:647-55.

More recently, three randomized controlled trials conducted in Zimbabwe, Kenya, and Bangladesh found no significant difference in child height between trial groups exposed to WASH interventions and control groups without the benefit of those interventions. These trials have called into question previous correlations between WASH and stunting. More follow up is needed to explore these questions further.

Quantitative Analysis

Impact: 

  Mixed

Strength: 

  Limited

 

Based on the linear mixed effects regression, decrease in open defecation significantly influenced stunting prevalence in the expected direction for the 2000-2016 period. The significance level was high (1 percent level), but effect size was small (0.03). This relationship did not hold for the 2008-2016 period, when open defecation was not found to be significantly associated with stunting. Improved drinking water source was not found to be significantly associated with stunting prevalence.

According to the decomposition analysis, open defection did not have a significant effect on HAZ within the general under-five population. It contributed a larger share of predicted change in HAZ among children under 6 months during the 2008-2016 period, but data in this age group are less reliable. Access to improved drinking water sources was not significant for any age group or time period.

Qualitative Analysis

Impact: 

  Mixed

Strength: 

  Limited

 

Not specifically mentioned. However, handwashing was an important part of the child growth monitoring intervention incentivized by Juntos and funded by PAN, which were both cited by stakeholders as being important.

Conclusion

Our analysis provided some evidence that improvements in clean water access and reduction in open defecation rates have positive impact on child HAZ trajectories. Improved WASH is supported in some global literature and previous Peru studies as contributing to reduction in stunting and general improvements in nutrition. These environmental conditions most obviously lead to immediate determinants of child stunting in Peru such as infectious diseases, including diarrhea and pneumonia.

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  1. 1
    Checkley W, Epstein LD, Gilman RH, Cabrera L, Black RE. Effects of acute diarrhea on linear growth in Peruvian children. Am J Epidemiol [Internet]. 2003;157:166-75.
  2. 2
    Lee GO, Paredes Olortegui M, Salmón-Mulanovich G, Peñataro Yori P, Kosek M. Early child health in an informal settlement in the Peruvian Amazon. BMC Int Health Hum Rights [Internet]. 2016;16:1-9.
  3. 3
    Lee G, Yori P, Olortegui MP, Pan W, Caulfield L, Gilman RH, Sanders JW, Delgado HS, Kosek M. Comparative effects of vivax malaria, fever and diarrhoea on child growth. Int J Epidemiol [Internet]. 2012;41:531-9.
  4. 4
    Acosta GJ, Vigo NI, Durand D, Riveros M, Arango S, Zambruni M, Ochoa TJ. Diarrheagenic Escherichia coli: prevalence and pathotype distribution in children from Peruvian rural communities. Am J Trop Med Hyg [Internet]. 2016;95:574-9.
  5. 5
    Jaganath D, Saito M, Gilman RH, Queiroz DMM, Rocha GA, Cama V, Cabrera L, Kelleher D, Windle HJ, Crabtree JE, et al. First Detected Helicobacter pylori Infection in Infancy Modifies the Association Between Diarrheal Disease and Childhood Growth in Peru. Helicobacter [Internet]. 2014;19:272-9.
  6. 6
    Passaro DJ, Taylor DN, Gilman RH, Cabrera L, Parsonnet J. Growth slowing after acute Helicobacter pylori infection is age-dependent. J Pediatr Gastroenterol Nutr [Internet]. 2002;35:522-6.
  7. 7
    Joseph SA, Casapia M, Montresor A, Rahme E, Ward BJ, Marquis GS, Pezo L, Blouin B, Maheu-Giroux M, Gyorkos TW. The Effect of Deworming on Growth in One-Year-Old Children Living in a Soil-Transmitted Helminth-Endemic Area of Peru: A Randomized Controlled Trial.[Erratum appears in PLoS Negl Trop Dis. 2015 Dec;9(12):e0004288; PMID: 26636967]. PLoS Neglected Trop Dis [electronic Resour [Internet]. 2015;9:e0004020.
  8. 8
    Hollm-Delgado M, Gilman RH, Bern C, Cabrera L, Sterling CR, Black RE, Checkley W. Lack of an adverse effect of Giardia intestinalis infection on the health of Peruvian children. Am J Epidemiol [Internet]. Oxford University Press / USA; 2008;168:647-55.