Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India

Abstract

Background Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition. Objectives We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India. Methods In this observational study, we used district-level data from before (2013–2014) and after (2015–2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates. Results Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: –0.10, –0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM. Conclusions An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.

Association between vaccine preventable diseases in children and improved sanitation following a nationwide sanitation campaign in India: an ecological analysis

“…As an exploratory exercise, we examined whether change in u5 child undernutrition—modelled as change in percentage of u5 children who are stunted—mediates the association between toilet availability and measles among u5 children in our analysis. We retrieved district-level data on u5 stunting from the NFHS, DLHS and AHS data sets (for details of this process, see Singh et al ) 30. We applied structural equation modelling techniques to examine direct, indirect and total effects of change in percentage of households with toilets on change in measles among u5 children, with change in u5 stunting specified as a mediator (online supplemental appendix table A.5).…”

“…In addition, we could not analyse urban and rural regions separately because the HMIS data do not report annual incidence of VPD by rural/urban divisions within districts. Owing to data limitations, we also cannot examine differential responses by gender or age groups 30. Data limitations also did not permit a more nuanced spatial analysis that takes into consideration the similar of some adjacent districts (but not others) within a region with respect to sanitation and measle incidence.…”

“…In addition, for any results which rejected the null, we then reformulated the outcome as change in counts (as opposed to per 1000 annual incidence) of VPDs in u5 children per district to obtain the average marginal effect of change in exposure on the outcome (case counts). We also conducted exploratory analyses of mediation (child undernutrition modelled as stunting among u5 children)30 and sensitivity to additional covariates that may influence VPDs that exhibit statistically detectable associations with the exposure. Finally, for tests that rejected the null, we conducted robustness checks to examine whether our analytic results and inference were influenced by outliers.…”

“…Recent work suggests that increased toilet availability following SBM may have reduced child undernutrition30 and diarrheal outbreaks 31. However, we know of no work that examines whether these improvements extend to reduced annual incidence of VPDs among u5 children.…”

India’s National Sanitation Policies: Evolution, Impact and Recommendations

“…The mission has brought about positive health impacts by promoting better hygiene practices. Increased access to toilets has decreased waterborne diseases and improved child height-for-age (stunting), contributing to overall improvements in community health (Dandabathula et al, 2019; Singh et al, 2021). SBM emphasised BCC to shift cultural norms and attitudes towards open defecation.…”