Association between water, sanitation, and hygiene practices (WASH) and anthropometric nutritional status among selected under- ﬁ ve children in rural Noakhali, Bangladesh: a cross-sectional analysis Uncorrected

This study aims to ﬁ nd out how WASH practices may be responsible for the development of diarrheal disease and poor physical growth of under- ﬁ ve children in rural Noakahli, Bangladesh. A case study was conducted among 110 households who had children aged between 0 and 59 months chosen by simple random method at Noakhali district, Bangladesh. Bivariate and multivariate logistic regression was employed to ﬁ nd the association. About 40.1% of children had diarrhea within 1 week prior to the study and 38.9% had skin problems of different kinds. A signi ﬁ cant association between wasting and hand washing before feeding the baby ( p < 0.006) was found; stunting and family income also showed association ( p < 0.003). Bathing the baby regularly, cleaning toilets, and cleanliness of the baby was found to be strongly associated; not cleaning toilets was associated with a very high risk of getting diarrhea (AOR: 16.397 (1.075 – 250.013)). Moreover, the unavailability of soaps in toilets increased the risk of diarrheal diseases (COR: 3.933 (1.258 – 12.296)) in the study population. Malnutrition is highly prevalent in children living in the study area and needs to be addressed by considering the factors which affect this rate.


INTRODUCTION
One study reported that children living in unsanitary and unhygienic environments may become undernourished even in the absence of diarrhea or intestinal worms (Humphrey ). A child may develop a condition known as environmental enteropathy due to repeated ingestion of fecal bacteria. Consequently, it may overload the gut and cause malabsorption, leaking mucosa, poor villi functioning, and inflammation of gut cells that may lead to body faltering (Ngure et al. ; Burton et al. ). One study conducted in Gaza Strip revealed that the availability of sewage water around the household increases the risk of acute diarrhea.
The study concluded that a closed sewerage system coupled with a clean safety tank and good handwashing practice before and after eating could significantly reduce acute diarrhea in under-five children (Abuzerr et al. ), which shows the significance of WASH in the control of diarrhea.

METHODOLOGY Study design and study population
The study was cross-sectional in nature. The study duration was from December 2019 to February 2020 in Bangla bazar, Sadar Upazilla, Noakhlai, Bangladesh. The area was selected randomly among rural villages and the households were also chosen randomly from the villages, however, it cannot be claimed to be representative of the total population. A total of 110 housesholds were chosen randomly with mother/caregiver and children pairs from Noakhali, who willingly agreed to participate in the study. The calculation of sample size used Cochrane's' equation having a precision level at 0.1, 90% confidence limit, and 31% as probability fraction (according to the BDHS, the undernutrition rate in Bangladesh is 31%) (BDHS 2019) and a design effect of 1.7. The sample size was calculated using the After adding a 10% non-response rate the minimum sample size of the study was 107; however, information from 110 households was finally collected. The study considered under-five children since they are mostly dependent.
Their hygiene and sanitation practices depend on mothers/caregivers' practice; hence the main respondents were mothers/caregivers and they were asked how they maintain and practice basic hygiene and sanitation relating to their child. As the children spend most of the time with their mother and the mother is typically the primary caretaker of the family; therefore, children's hygiene ad sanitary practices are mostly dependent on the mother

Data collection tools and techniques
A questionnaire was developed containing closed-ended questions to obtain relevant information on socioeconomic, anthropometric, sanitation, and hygiene practice. All questions were designed, pre-tested, modified, and adjusted.
The purpose of the pre-test was to test the content, working expression, the topical sequence of questions, duration of the interview, and the reliability of some items. After pretesting the individual questionnaire, which was related to quantitative data, was improved and reformed to ensure content coverage, reliability, and validity of the study.

Age detection
The age of the subjects under study was determined by interrogation and confirmed through probing. The age of the children was collected from parents, and they were asked to bring the children's birth certificate or immunization cared. If parents were unable to say the exact age of their children, then additional probing was carried out.
For instance, if they can remember any national events or religious programs when their child was born.

Measuring body weight
Weight was recorded in kilograms by using a standard weighing machine. During measuring the children's weight, each subject was barefooted and heavy clothing was removed to measure the exact weight. If a child was unable to stand then the mother took the child in her lap and later the mother's weight was deducted. The measurements were taken twice and sometimes three times if the difference between the consecutive two measurements was too large.

Measuring height
For measurement of height, subjects were positioned to stand on the platform, barefoot, with their head upright, looking straight forward by using a standard height measurement scale. Height was measured to the nearest 0.1 cm. A length measuring board was used if a child was unable to stand or was below two years of age. The measurements were taken twice and sometimes three times if the difference between the consecutive two measurements was too large.

Data verification
Standard procedures in measurements were applied carefully in every stage of measurements. Questionnaires were checked each day after interviewing and again these were carefully checked after completion of all data collection and coded before being entered on to a computer. To minimize errors, all the data were checked for consistency and outliers and corrected accordingly.

Assessment of nutritional status
The nutritional status of school children was assessed by anthropometric measurements, i.e. height in centimeters (cm), and weight in kilograms (kg

Assessment of hygiene and sanitation practices
Some basic hygiene practice-related questions were asked, for example type of toilets, cleaning materials for handwashing and how frequently they are used, source of water, cleanliness of body, etc.

The occurrence of diarrheal disease
Respondents were asked if the child had experienced any diarrheal disease within the last week (of the survey). Developing diarrheal disease in the last week prior to the survey was considered as poor maintenance of household hygiene and sanitation though a critical link cannot be developed since a cause-effect relationship is difficult for a cross-sectional study.

Outcome and predictor variables
The primary outcomes of the study were the occurrence of diarrheal disease within the last week of the survey and also the indicators of nutritional status (underweight, stunting, and wasting). The predictor variables were WASH practices and various socio-demographic variables that can affect the association. The two-way pathway was created in a sense that the effect of WASH variables may be difficult to observe directly in the development of poor physical growth of under-five children since many factors may confound the situation. The most prevalent consequence of poor WASH practices is diarrhea, which has been considered to study. It may give clear identification of how diarrheal disease development in the children has been influenced by poor household practices.

Data analysis and variable information
Data were processed and analyzed statistically by using SPSS software version 23. Descriptive statistics for water, hygiene, and sanitation practices, along with some basic socio-demographic characteristics of the study population, were performed. To assess the effect of socio-economic variables on children's anthropometric status, a chid-square test was performed. The frequency of diarrheal diseases and its effect on anthropometric status was also assessed. Binary and multivariate logistic regression was performed to assess how various sanitation and hygiene practices contributed to the development of recent diarrheal diseases. The odds ratio was determined and is reported in the results section, with 90% CI and a p-value of <0.1 was considered statistically significant.

Ethical consideration
Ethical permission was taken from the ethical board of Noakhali Science and Technology University, Bangladesh.
Consent from the respondents was also taken before the study. All the international standards of ethical rules and regulations were maintained.     There was no significant relationship between the parent's education and the nutritional status of the child. However, the descriptive statistics showed that the children's nutrition status improved with the increasing educational level of the mother to some extent.
In the present study the nutritional status of the children was found to be better than the children whose mother did not wash her hands before feeding the baby. There was a strong relationship between the handwashing practice of the mother and the nutritional status of the child.
Monthly income is one of the important indicators to describe the nutritional status of the children. The relation between monthly income of the family and HAZ score was found to be significant and an increasing family income decreased the stunted percentage of the under-five children.
In Table 4, the association between the occurrence of diarrhea and personal hygiene were identified in terms of bivariate analysis with crude odds ratio (COR) and the adjusted odds ratio (AOR) and 95% confidence interval was used (CI). It was found that those who used ash or soil as a handwashing material had 0.254 times (0.081,0.795; 95% CI) higher tendency to have diarrhea than the children who had used soap. The frequency of cleaning toilets was also found to have an association with diarrheal disease cases. Another strong association between bathing a child regularly and skin diseases were found. It

DISCUSSION
The study aimed to determine the relationship between the anthropometric status of the under-five children with household sanitation practice (WASH) in the rural areas Noakhali, Bangladesh. The study found out that more than half of the children deviated from good nutritional status. Some hygiene practices which are related to the occurrence of diarrhea, such as toilet type, cleanliness of the toilet, frequency of cleaning toilets, using sandals during going to the toilet and materials used after, and among these practices handwash materials, availability of soap, toilet cleaning, and frequency of toilet cleaning were found to be associated with the occurrence of diarrhea and specifically cleaning of toilets was strongly associated with it. A study conducted in the Gaza strip also found a significant association between the occurrence of diarrhea and the cleaning of hands before and after eating, as well as after

STUDY LIMITATIONS
This study has some limitations, including study implementation in a small geographic area, insufficient data on dietary patterns of the local populations, and lack of ability to compare these data to the population outside this rural area. Besides, hygiene practices could have been overreported, as it is common with all self-reported practices in personal interviews.

DATA AVAILABILITY STATEMENT
Data cannot be made publicly available; readers should contact the corresponding author for details.