WASH practices increased the prevalence of malnutrition among under-five children (6–59 months) in an urban slum area in Ibadan, Nigeria

Malnutrition remains the most prevalent threat to public health, especially in low- and middle-income countries, which are characterized by poor socio-economic conditions (World Health Organization (WHO) 2021). The term ‘malnutrition’ refers to three broad categories including undernutrition, micronutrient-related malnutrition (also known as hidden hunger), and overweight, which develops as a result of deficiencies, excesses, or imbalances in energy and/or nutrient intake (WHO 2021). The first 1,000 days of a child's life commonly referred to as the ‘window of opportunity’ is crucial to a child's development and essential for the prevention of malnutrition and its consequences (United Nations International Children's Emergency Fund (UNICEF) 2023a). Malnutrition has been accounted as a direct cause of 45% of all deaths among children under 5 years of age with undernourished children being at a higher risk of developing common diseases, who develop infections more frequently and severely with delayed recovery (UNICEF 2023a, 2023b). In 2020, 149 million children were estimated to be too short for their age (stunted), while 45 million and 38.9 million children were estimated to be too thin for their height (wasted) and overweight, respectively, worldwide (WHO 2021); and about two-thirds of this population were found in Sub-Saharan African nations (Black et al. 2013). About 32% of under-five Nigerian children were stunted, accounting for the second highest burden of global stunted children, while another 18.4 and 6.5% were adjudged to be underweight and wasted, respectively (UNICEF 2023a).

Adequate and equitable access to improved water, sanitation, and hygiene (WASH) is essential for the global development of public health. Access to potable drinking water supply and proper sanitation facilities is a fundamental human right and one of the sustainable development goals (SDGs) aimed to be achieved by the year 2030 (United Nations 2017). However, in 2020, 411 million people still lacked access to basic water services, 839 million people lacked basic hygiene services, and another 779 million lacked basic sanitation services, of which 208 million practice open defecation in Africa (UNICEF 2022). A 2017 report from the World Health Organization and United Nations Children's Fund shows that 263 million spent over 30 min per round trip to get safe water from an improved source and 159 million people are still collecting water from the surface, especially in Sub-Saharan Africa (WHO 2017). In 2018, nearly 29 and 61% of the global population lacked adequate drinking water and basic sanitation facilities, respectively (United Nations 2017). Nigeria is one of the countries faced with major difficulties in providing improved access to water, sanitation, and hygiene (National Population Commission (NPC) [Nigeria] and Inner City Fund (ICF) 2019), which could be attributed to rapid urbanization and increasing population growth. The uncontrollable influx of people migrating from rural to urban areas could, therefore, have adverse effects on sanitation practices due to overcrowding in communities, limited access to high-quality housing facilities, and reduced availability of clean water. The 2018 Nigerian Demographic Health Survey (NDHS) showed that about 34% of the population lack access to improved water sources and 25% still practice open defecation across the country, out of which 26 and 15% were found in urban areas, respectively (NPC [Nigeria] & ICF 2019). Poor access to potable water supply and a hygienic environment pose severe threats to the nutrition and health status of individuals, especially under-five children increasing their risk of contracting enteric infections that could be life-threatening if not properly managed. The consequence of poor WASH practices mostly affects populations in Sub-Saharan Africa and Central Southern Asia (Yaya et al. 2018). Mortality rates associated with unimproved WASH practices account for 84 per 1,000 live births among under-five children in Sub-Saharan Africa (United Nations 2017). Among under-five children, the lack of improved WASH results in about 1.7 billion cases of diarrhea and results in 842,000 deaths per year (Alua et al. 2018). According to the NDHS data, diarrhea was more prevalent among under-five children with poor access to portable drinking water and poor sanitation practices (NPC & ICF 2019). Diarrhea is ranked the second leading cause of death of under-five children accounting for 17–23% of deaths (Odejimi et al. 2022). Children living in unhygienic environments are susceptible to malnutrition as a result of recurrent infections resulting from an overload of parasites that interferes with the digestion process and absorption of nutrients thereby leading to a weakened immune system (Ademas et al. 2021). Malnutrition is a major health concern because a large number of young children die each year due to complications resulting from poor nutritional status (Koletzko 2015). Malnutrition coupled with high incidences of infections accounts for the high mortality rates observed among children in developing countries like Nigeria. Previous studies have shown an association between household water, sanitation, and hygiene practices and stunting, wasting, and being underweight among under-five children (Yaya et al. 2018; Shrestha et al. 2020). Also, recurrent parasitic infections during childhood have been associated with physical weakness, low educational performance, and long-term consequences on cognitive performance as well as reduced work productivity during adulthood (Guerrant et al. 2002; Gelaw et al. 2013). Previous studies have estimated that about 45% of child deaths relating to malnutrition could be prevented through improved WASH practices (Curtis & Cairncross 2003; Black et al. 2013). Slums and other low-income areas are a peculiar example of the gravity of child malnutrition in developing countries (Kimani-Murage et al. 2011). They are usually characterized by poor living conditions including food preparation and consumption practices with no cognizance of food safety measures. In light of this, this study evaluated the association between WASH practices and the nutritional status of children (6–59 months) in an urban slum area in Ibadan, Nigeria. We aim to produce a clearer picture and provide the insight required for policy decisions.

This cross-sectional descriptive study was conducted among children (6–59 months) with their mothers/caregivers in an urban slum area in Ibadan, Oyo State, Nigeria. The study was conducted between May and June 2022.

The Ibadan Northeast local government is one of the local government areas in Ibadan that have slum areas. There are 12 wards in the local government and 2 wards that inhabit the predominant slum area were selected. The communities selected were categorized as urban slums based on the definition by van der Horn (2012) and Wrathall (2014). Simple random sampling using balloting was used to select the communities within the wards. A cluster sampling technique was used to select households with under-five children within the communities according to their house structure and community layout.

Considering the 10% non-response rate, the sample size was 204 and was approximated to be 210. About 210 children aged 6–59 months were recruited in this study; however, during data cleaning, 200 questionnaires were eligible for analysis.

Semi-structured interviewer-administered questionnaire adapted from previous works of literature related to the study was used to collect information from the mothers/caregivers of the children on water, sanitation, and hygiene practices. An environmental observational checklist was used to assess the physical environment of the children. Anthropometric measurements of height, weight, and mid-upper arm circumferences were taken for the index child to determine their anthropometric status.

Weight: A digital weighing body scale was used to assess the weight of the children to the nearest 0.1 kg. The weighing scale was placed on a levelled surface and children who could stand without support were allowed to stand on the weighing scale. The weight of children who could not stand at the time of data collection was measured by taking the weight of the mother/caregiver with the child and the weight of the mother/caregiver without the child, and the final weight of the child was determined by calculating the difference between the two weights measured. It was ensured that the children put on lightweight clothes and were without shoes at the time of measurement.

Height/length: The height of each child was also measured using a Stadiometer to the nearest 0.1 cm. The children were made to stand against a vertical wall and also removed their shoes before taking the measurement. Recumbent length was used to determine the length of children who could not stand at the time of data collection.

Mid-upper arm circumference (MUAC): The mid-point between the tip of the shoulder and the tip of the elbow of the left arm was marked with the arm crossed to the stomach. The MUAC tape was wrapped around the arm at the mid-point marked and the reading was recorded to the nearest 0.1 cm.

Anthropometric measurements were analyzed using WHO-Anthro software to determine height-for-age, weight-for-age, and weight-for-height z-scores using WHO standards and transferred to SPSS for further analysis. All data obtained were analyzed using IBM SPSS Statistics version 25, and descriptive statistics such as frequencies, percentages, means, and standard deviations were determined. Chi-square analysis was used to test for association between variables with a level of significance at 0.05.

Table 1 shows the summary of the sociodemographic characteristics of the children. The result showed that the majority of the children were females (77.5%) and were between 24 and 59 months (60.5%), with a mean age of 30 ± 4 months. The family structure showed that most of the children were from monogamous families (64.0%) with household sizes between 4 and 6 persons (46.5%) per household. Secondary education (51.0 and 40.5%) was the highest educational level attained by both fathers and mothers of the children, and they were mostly traders (46.0 and 47.0%, respectively), who lived in rented apartments (60.5%). The anthropometric status of the children shows that less than half of the children had height-for-age (44.0%), weight-for-height (37.5%), and weight-for-age (34.0%) below −2 SD z-score, while 14.5 and 24.0% had moderate and severe acute malnutrition, respectively.

Table 2 below shows the WASH practices of the children and their caregivers/mothers. The result showed that the major source of domestic water was from a deep well (71.5%), while drinking water was from a tap/borehole (83.0%), which takes less than 15 min (36.5%) to access for the household. However, almost one-third of the households (31.5%) took 16–30 min to get access to their source of water. About one-quarter (25.5%) of the households purified their water before drinking by either adding alum, (64.7%), boiling (11.7%), or filtering (5.9%). The majority (89.0%) of the mothers/caregivers washed their hands after using the toilet with soap and water (68.0%) and also washed their hands before feeding the child (87.5%) with clean water only (56.0%). The mothers/caregivers reported that most of the children washed their hands after using the toilet (89.0%) with soap and water (70.2%), bathed twice daily (84.0), and brushed their teeth once a day (93.0). Plastic and paper wastes (72.0%), stagnant wastes (62.5%), and animal feces (51.5%) were mostly found in their environment. Household wastes were mostly disposed of in the river (60.8%). The most common type of toilet in the communities was a pit latrine (34.0%).

Table S1 shows the hygiene and sanitation checklist observed by the researcher. The physical observation of both the caregiver and the index child showed that they lived in a dirty environment (81.6%), which had drainage (91.0%) but was dirty (77.6%). More than half of the respondents had flies (67.0%) and domestic animals (51.5%) around the house. The majority of both mother/caregiver and index child had trimmed nails (63.2 and 97.4%), respectively; however, the index child appeared dirty (76.0%) on the day of data collection.

Child feeding practices are shown in Table S2. About one-quarter (26.0%) of the children were exclusively breastfed and almost half (48.0%) used bottles to feed. Most of the mothers/caregivers reported that the child's feeding utensils are usually cleaned with soap and water only (79.5%). Almost half of the children had episodes of diarrhea in the past month (48.5%), while 31.5% had diarrhea in the past week of data collection. The majority of the caregivers reported seeking medical attention (43.0%), while 35.5% used oral rehydration salt therapy for the child.

Table 3 shows the relationship between the nutritional status, sociodemographic, and WASH practices of the respondents. The result showed that there was a significant relationship between the sex of the child and the nutritional status of the children (p < 0.05). Stunting, wasting, and underweight were more prevalent among females compared to males. Household income, time to source drinking water, and washing of child's hands before feeding showed a significant relationship with stunting (p < 0.05) as the majority of the children from lower socio-economic classes as well as those who spend more time to get access to water were more stunted. Family structure and household income showed a significant relationship with being underweight (p < 0.05). More than half of the respondents from polygamous homes, with lower household income, and spent more time sourcing water were more underweight.

This study assessed the relationship between WASH practices and the anthropometric status of under-five children in an urban slum area of Ibadan, Nigeria. Overall, the result showed that there was a high prevalence of undernutrition among the under-five children as almost half were stunted, and more than one-third were underweight and wasted, respectively. The prevalence of stunting, wasting, and underweight reported in this study was higher than previous findings in other parts of Nigeria among under-five children (Ozor et al. 2014; Jimoh et al. 2018; Olodu et al. 2019), but the prevalence of stunting was lower than the result observed in Ethiopia and Bangladesh (Ghosh et al. 2021; Sahiledengle et al. 2022).

Inadequate access to clean, drinkable water is a predisposing risk factor for diarrhoeal episodes in under-five children (Oloruntoba et al. 2014; He et al. 2018) and subsequently malnutrition. This is evident also from the results of this study which identified that the closest source of water was 15 min away and about a third of the children had a recent diarrhea episode the week prior to data collection. Children whose source of water was more than 15 min away had a greater risk of being stunted and underweight similar to findings in Ethiopia where the time to source of water was associated with stunting among under-five children (Sahiledengle et al. 2022). The high rate of diarrhea observed in this study could possibly be attributed to cross-contamination of water and an unhygienic environment. Although most of the mothers in this study reported using a deep well or borehole as their source of domestic and drinking water and that they purified the water using alum, the majority of them stored the water in water drums and covered buckets, which might lead to cross-contamination of the water supply. According to the findings from previous research, improper water storage, particularly storage in large apertures, may make it easier for feces to contaminate the water and has been linked to an increased rate of diarrhea in children (Jinadu et al. 1991; Oloruntoba et al. 2014). Recurrent diarrhea has also been associated with undernutrition, especially stunting and wasting among under-five children (Ghosh et al. 2021). Diarrhea is one of the most common life-threatening infections in under-five children, and it can impede food intake, nutrient absorption, and utilization, thereby jeopardizing optimal nutritional status.

Poor hygiene and sanitation practices observed in this study could be a significant contributor to the high rate of undernutrition among the under-five children. Inadequate sanitation and hygiene practices are key contributors to undernutrition in under-five children. Most of the households in this study do not have toilet facilities and they either used pit latrines or bushes for defecation. The use of a latrine has been associated with an increased prevalence rate of stunting and children who live in households where open defecation is practiced are at a greater risk of becoming stunted (Sahiledengle et al. 2022). The unhygienic environment that was characterized by the presence of human and animal feces, as well as stagnant wastes, could be a compounding factor to the prevalence of stunting observed in this study, which was higher than in previous Nigerian studies (Ozor et al. 2014; Jimoh et al. 2018; Olodu et al. 2019). Studies have reported an association between stunting and an unhygienic environment among under-five children (Rahman et al. 2020; Ademas et al. 2021). Poor sanitation and hygiene practices open the door to a wide variety of opportunistic infections, particularly bacterial and viral diseases such as diarrhea, typhoid, cholera, and dysentery, which are very common in young children and are associated with undernutrition. A previous study in Nigeria has observed a statistically significant relationship between poor living environments and the risk of diarrhea among under-five children (Yaya et al. 2018). Poor water handling, close proximity drainage, the presence of flies and domestic animals, and a dirty environment were observed in this study, which implies that five out of the six WASH-related risk factors reported by Oloruntoba et al. (2014) that increase the risk of diarrhea among under-five children were found in our study. A clean and safe environment as well as proper waste management is therefore essential in preventing the transmission of diseases among young children.

A significant relationship was also found between household income and the anthropometric status of the children. There is a higher prevalence rate of stunting and underweight status among children from low-income parents. The parents had a low income for their household on a monthly basis, and they rented an apartment in an urban slum region of the town. A similar study also observed a significant relationship between family income and nutritional status in Bangladesh (Ghosh et al. 2021) with improved nutritional status reported among families with higher income. Children from high socio-economic classes have access to clean and safe water, in addition to a clean environment, which reduces the likelihood that these children will suffer from diarrhea as compared with those who live in unhygienic environments (Hong et al. 2006) and consequently an improved nutritional status.

Access to unsafe water was significantly associated with malnutrition among the children. WASH practices have a significant relationship with the anthropometric and overall nutritional status of under-five children. Poor WASH practices increase the risk of enteric infections, which result in reduced food intake, frequent stooling, poor nutrient absorption, nutrient loss, and consequently poor nutritional status. The vicious cycle between WASH and malnutrition has a long-term effect on the growth and development of children and may also worsen their overall health status. Poor health status also poses serious threats to households and the nation at large as it reduces productivity. This study identified several factors that impact the nutrition and growth of the studied children. The result of this study considers how important it is for society as a whole to contribute to the cleanliness of their environment as this is significant to the overall health status of the future generation. Therefore, there is a need to educate and encourage mothers/caregivers to improve their hygiene practices within the community in order to achieve sustainable development goal 6 (access to clean and safe water for all). This is because access to safe water, environmental sanitation, proper waste management, and facilities can only be achieved through collective and integrated efforts of individuals, communities, government agencies, non-profit organizations, and commercial organizations. The government can also work alongside non-governmental organizations to develop projects aimed at improving the WASH conditions in the communities.

Ethical approval was obtained from the Lead City University Ethical Review Committee with ethical number LCU-REC/22/118 before the commencement of data collection. All the respondents were briefed about the purpose of the study and verbal consent was taken at the point of administration of the questionnaires.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.