The Effect of Improved Water, Sanitation and Hygiene on Linear Growth Amongst Children Living in Developing Countries: A Systematic Review

  • Elton Chavura Mzuzu University, Faculty of Environmental Science, Mzuzu, Malawi
  • Wales Singini Mzuzu University, Faculty of Environmental Science, Mzuzu, Malawi
  • Russel Chidya Mzuzu University, Faculty of Environmental Science, Mzuzu, Malawi
  • Balwani Chingatichifwe Mbakaya University of Livingstonia, Department of Public Health, Malawi
Keywords: Systematic review, WaSH, Linear Growth, Environmental Enteric Dysfunction, Sanitation, Improved Water Supply, Stunting


Constant exposure to poor water, sanitation and hygiene (WaSH) contribute to environmental enteric dysfunction; a disorder that is frequently implicated as a cause of linear growth failure. We aimed to evaluate the efficacy of WaSH on linear growth amongst children aged 0-59 months. We reviewed fourteen (14) studies retrieved from AMED, CINAHL, DOAJ, PubMed, PsycINFO, Google Scholar, and EMBASE databases following guidelines developed by PROSPERO and COCHRANE. The screening process was summarized using a PRISMA flow diagram, and the methodologies were critically appraised by a Mixed Method Appraisal Tool. The following search terms were employed in the search strategy: sanitation and/or improved water supply and/or WaSH and/or stunting and/or linear growth and/or environmental enteric dysfunction. No difference was seen in mean height for age Z-score (0.01, 95% CI-0.16 to 0.18) between children who received WaSH interventions and those who did not. Only five (5) studies reported a significant association between WaSH and child linear growth (P < 0.001). All combination intervention studies included in this review did not establish any significant benefit of WaSH and nutrition integration, presumably due to methodological limitations and a short duration of exposure to the interventions. Although robust sanitation coverage could be an important component amongst proven interventions to stimulate linear growth, stunted growth is embedded within myriad determinants beyond improved WaSH. More research is needed to quantify the complementary effect of WaSH and nutrition co-programming. This systematic review was registered in the PROSPERO database with registration number CRD42022322462.


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1. Bekele, T., Rahman, B. and Rawstorne, P., 2020. The effect of access to water, sanitation and handwashing facilities on child growth indicators: evidence from the Ethiopia demographic and health survey 2016. PLoS One, 15(9), p.e0239313.
2. Berhanu, G., Mekonnen, S. and Sisay, M., 2018. Prevalence of stunting and associated factors among preschool children: a community based comparative cross sectional study in Ethiopia. BMC nutrition, 4(1), pp.1-15.
3. Budge, S., Parker, A.H., Hutchings, P.T. and Garbutt, C., 2019. Environmental enteric dysfunction and child stunting. Nutrition reviews, 77(4), pp.240-253.
4. Chandna J, Ntozini R, Evans C, et al. Effects of improved complementary feeding and improved water,sanitation and hygiene on early child development among HIV exposed children: substudy of a cluster randomised trial in rural Zimbabwe. BMJ Global Health 2020;5:e001718. doi:10.1136/ bmjgh-2019-001718.
5. Christian, P., Hurley, K.M., Phuka, J., Kang, Y., Ruel-Bergeron, J., Buckland, A.J., Mitra, M., Wu, L., Klemm, R. and West Jr, K.P., 2020. Impact evaluation of a comprehensive nutrition program for reducing stunting in children aged 6–23 months in rural Malawi. The Journal of Nutrition, 150(11), pp.3024-3032.
6. Deichsel, E.L., Pavlinac, P.B., Richardson, B.A., Mbori‐Ngacha, D., Walson, J.L., McGrath, C.J., Farquhar, C., Bosire, R., Maleche‐Obimbo, E. and John‐Stewart, G.C., 2019. Birth size and early pneumonia predict linear growth among HIV‐exposed uninfected infants. Maternal & Child Nutrition, 15(4), p.e12861. 28
7. Evans, E.E. and Siedner, M.J., 2017. Tropical Parasitic Infections in Individuals Infected With HIV. Current tropical medicine reports, 4(4), pp.268-280.
8. Fenn, B., Bulti, A.T., Nduna, T., Duffield, A. and Watson, F., 2012. An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia. Public health nutrition, 15(9), pp.1746-1754.
9. George, C.M., Monira, S., Zohura, F., Thomas, E.D., Hasan, M.T., Parvin, T., Hasan, K.,Rashid, M.U., Papri, N., Islam, A. and Rahman, Z., 2021. Effects of a water, sanitation, and hygiene mobile health program on diarrhea and child growth in Bangladesh: a cluster-randomized controlled trial of the cholera hospital-based intervention for 7 days (CHoBI7) mobile health program. Clinical Infectious Diseases, 73(9), pp.e2560-e2568.
10. Hill, C.L., McCain, K., Nyathi, M.E., Edokpayi, J.N., Kahler, D.M., Operario, D.J.,Taylor, D.D., Wright, N.C., Smith, J.A., Guerrant, R.L. and Samie, A., 2020. Impact of low cost point-of-use water treatment technologies on enteric infections and growth 29 among children in Limpopo, South Africa. The American journal of tropical medicine and hygiene, 103(4), p.1405.
11. Hong, Q.N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M.P., Griffiths, F., Nicolau, B. and O’Cathain, A., 2018. Mixed methods appraisal tool (MMAT), version 2018. Registration of copyright, 1148552(10).
12. Humphrey, J.H., Mbuya, M.N., Ntozini, R., Moulton, L.H., Stoltzfus, R.J., Tavengwa, N.V., Mutasa, K., Majo, F., Mutasa, B., Mangwadu, G. and Chasokela, C.M., 2019. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. The Lancet Global Health, 7(1), pp.e132-e147.
13. JR, H. and Freeman, M.C., 2019. Integration of water, sanitation and hygiene and nutrition programming is associated with lower prevalence of Child stunting and fever in Oromia, Ethiopia. African Journal of Food, Agriculture, Nutrition & Development, 19(4).
14. Keusch, G.T., Rosenberg, I.H., Denno, D.M., Duggan, C., Guerrant, R.L., Lavery, J.V.,Tarr, P.I., Ward, H.D., Black, R.E., Nataro, J.P. and Ryan, E.T., 2013. Implications of acquired environmental enteric dysfunction for growth and stunting in infants and children living in low-and middle-income countries. Food and nutrition bulletin, 34(3), pp.357-364.
15. Luby, S.P., Rahman, M., Arnold, B.F., Unicomb, L., Ashraf, S., Winch, P.J., Stewart, C.P., Begum, F., Hussain, F., Benjamin-Chung, J. and Leontsini, E., 2018. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. The Lancet Global Health, 6(3), pp.e302-e315.
16. Moher D, Liberati A, Tetzlaff J, Altman DG GP. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7). 27
17. Null, C., Stewart, C.P., Pickering, A.J., Dentz, H.N., Arnold, B.F., Arnold, C.D., Benjamin-Chung, J., Clasen, T., Dewey, K.G., Fernald, L.C. and Hubbard, A.E., 2018. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial. The Lancet Global Health, 6(3), pp.e316-e329.
18. Prendergast, A.J., Chasekwa, B., Evans, C., Mutasa, K., Mbuya, M.N., Stoltzfus, R.J., Smith, L.E., Major, F.D., Tavengwa, N.V., Mutasa, B. and Mangwadu, G.T., 2019. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on stunting and anemia among HIV-Exposed children in rural Zimbabwe: a cluster randomized controlled trial. The lancet child and adolescent health, 3(2), pp.77-90.
19. Reese, Heather, Parimita Routray, Belen Torondel, Sheela S. Sinharoy, Samir Mishra, Matthew C. Freeman, Howard H. Chang, and Thomas Clasen. "Assessing longer-term effectiveness of a combined household-level piped water and sanitation intervention on child diarrhoea, acute respiratory infection, soil-transmitted helminth infection and nutritional status: a matched cohort study in rural Odisha, India." International journal of epidemiology 48, no. 6 (2019): 1757-1767.
20. Saaka, M., Saapiire, F.N. and Dogoli, R.N., 2021. Independent and joint contribution of inappropriate complementary feeding and poor water, sanitation and hygiene (WASH) practices to stunted child growth. Journal of Nutritional Science, 10.
21. Shekar, M., Kakietek, J., Eberwein, J.D. and Walters, D., 2017. An investment framework for nutrition: reaching the global targets for stunting, anemia, breastfeeding, and wasting. World Bank Publications.
22. Simiyu, S.N., Kweyu, R.M., Antwi-Agyei, P. and Adjei, K.A., 2020. Barriers and opportunities for cleanliness of shared sanitation facilities in low-income settlements in Kenya. BMC Public Health, 20(1), pp.1-12.
23. Sofeu, C.L., Tejiokem, M.C., Penda, C.I., Protopopescu, C., Ateba Ndongo, F., Tetang Ndiang, S., Guemkam, G., Warszawski, J., Faye, A., Giorgi, R. and ANRSPEDIACAM study group, 2019. Early treated HIV-infected children remain at risk of growth retardation during the first five years of life: results from the ANRSPEDIACAM cohort in Cameroon. PLoS One, 14(7), p.e0219960.
24. Torlesse, H., Cronin, A.A., Sebayang, S.K. and Nandy, R., 2016. Determinants of stunting in Indonesian children: evidence from a cross-sectional survey indicate a prominent role for the water, sanitation and hygiene sector in stunting reduction. BMC public health, 16(1), pp.1-11.
25. Waddington, H. and Snilstveit, B., 2009. Effectiveness and sustainability of water, sanitation, and hygiene interventions in combating diarrhoea. Journal of development effectiveness, 1(3), pp.295-335.
26. Walles, J., Balcha, T.T., Winqvist, N. and Björkman, P., 2017. Growth pattern in Ethiopian infants–the impact of exposure to maternal HIV infection in relation to socioeconomic factors. Global health action, 10(1), p.1296726.
27. Watanabe, K. and Petri Jr, W.A., 2016. Environmental enteropathy: elusive but significant subclinical abnormalities in developing countries. EBioMedicine, 10, pp.25-32.
How to Cite
Chavura, E., Singini, W., Chidya, R., & Mbakaya, B. C. (2022). The Effect of Improved Water, Sanitation and Hygiene on Linear Growth Amongst Children Living in Developing Countries: A Systematic Review. European Scientific Journal, ESJ, 18(30), 296.
ESJ Natural/Life/Medical Sciences