NUTRITIONAL EFFECT OF WATER, SANITATION AND HYGIENE (WASH) ON

CHILDREN’S WELL-BEING

Engr. Julius A. Otitolaiye (MNSE)

An independent Researcher
Abstract
Globally, unsafe drinking water, poor access to appropriate sanitation facilities and inadequate
hand washing contribute significantly to childhood illness and death. Clean water, availability of
toilets and good hygiene practices are essential for the survival and development of children.
This paper examines the impact of Water, Sanitation and Hygiene (WASH )on the nutrition of
children, the effect on child’s health and the best practices. It therefore recommends that local,
state and national bodies’ capacity to develop and implement equitable and sensitive WASH
policies, strategies and guidelines should be strengthened.

Keywords – Sanitation, appropriateness, health, best practices, national bodies, WASH.

Introduction
Activities that aim at improving access to the use of safe drinking-water and sanitation as
well as promoting good hygiene practice is referred to as WASH. Clean water, availability of
toilets and good hygiene practices are essential for the survival and development of children.
Globally, there are 2.4 billion people who live without adequate sanitation, 663 million do not
have access to improved water sources and 946 million still defecate in the open (UNICEF,
2015). While there has been progress, it has been slow and uneven, with 96% of the global urban
population using improved drinking water sources compared to 84% of the rural population;
82% of the global urban population uses improved sanitation facilities compared to 51% of the
rural population. The World Health Organization (WHO) estimates that 50% of mal-nutrition is
associated with repeated diarrhea or intestinal worm infections as a result of unsafe water,
inadequate sanitation or insufficient hygiene. Lack of access to water, sanitation and hygiene
(WASH) has a huge impact on children’s health. (UNICEF, 2015)
Currently, 159 million children in the world are stunted as a result of malnutrition, their
cognitive and physical growth damaged irreversibly by their inability to obtain and absorb the
nutrients they need. Some 50% of malnutrition is linked to infections, worm infestations and
diarrheal illnesses Children under the age of five years are the most affected as they are prone to
water-borne diseases, especially diarrhea. It is estimated that over 800,000 children die annually
from preventable diseases caused by poor water, lack of sanitation and poor hygiene, (Mills,
2017). Diarrhea is one of the leading causes of morbidity and mortality in children, and while
there has been progress in the reduction of diarrhea-associated mortality. Waddington (2017), the
reduction in incidence and morbidity has varied in different regions and between socio-economic
classes. The use of contaminated drinking water and poor sanitary conditions result in increased
vulnerability to water-borne diseases, including diarrhea which leads to deaths of many children
under five annually. Seventy-three per cent of the diarrheal and enteric disease burden is
associated with poor access to adequate water, sanitation and hygiene (WASH), and is
disproportionately borne by poorer children.
Approximately, a third of all child deaths are attributable to nutrition-related factors, such
as low birth weight, stunting (low height for age) and severe wasting, all of which are closely
linked to a lack of access to water and particularly sanitation and hygiene. (Ngure et al 2014).
Many children in developing regions suffer stunting, which reflects chronic nutritional
deficiencies. A lack of sufficient, safe water close to home also has many indirect effects on
nutrition. Where safe water is available to purchase from vendors, a limited quantity leaves little
for good hygiene practices. The suffering from water-related illnesses has a significant impact on
the health and well- being of Children. However, world leaders have promised to end
malnutrition and deliver water and sanitation to everyone, everywhere by 2030.
Achieving important global health goals, such as ending preventable child and maternal
deaths, eliminating neglected tropical diseases and the global non communicable disease targets,
will require addressing malnutrition in all its forms. Lack of access to WASH can affect a child’s
nutritional status through at least three direct pathways: via diarrhea diseases, intestinal parasite
infections and environmental enteropathy. WASH interventions can positively impact all three of
these pathways and in turn improve nutrition.

Water, Sanitation and Hygiene (WASH)

WASH is an acronym that stands for "water, sanitation and hygiene". Universal,
affordable and sustainable access to WASH is a key public health issue within international
development and is the focus of Sustainable Development Goal 6. (UN, 2017) Inadequate
WASH services and practices are a major concern in households worldwide:
• Water. An estimated 663 million people worldwide do not have access to an improved
drinking-water source (UNICEF/WHO, 2015). An estimated 1.9 billion people rely on drinking-
water that is facially contaminated (Bain et al., 2014). Improved water sources that are not
operated or maintained properly may deliver water that is microbiologically contaminated
(WHO/UNICEF, 2011). In addition, microbial recontamination often occurs during collection of
water at the source, transport and storage within the home (Wright, Gundry & Conroy, 2004).
• Sanitation. An estimated 2.4 billion people, or one third of the world’s population, lack access
to an improved sanitation facility, and 13% practice open defecation. Among the world’s
regions, sub-Saharan Africa and South Asia continue to have the lowest sanitation coverage
(WHO/UNICEF, 2015).
• Hygiene. Unlike household access to drinking-water and sanitation, no global mechanism
exists to monitor hand washing practices in homes and communities. Furthermore, it is difficult
to obtain reliable global estimates on hand washing with soap. However, in a recent systematic
review of 42 studies of observed hand washing with soap in 19 countries, it was estimated that
only 19% of people worldwide wash their hands after potential contact with excreta (Freeman et
al.,2014). Despite indications of their importance for health and nutrition, few rigorous data exist
on food and environmental hygiene practices.
In 2015, the World Health Organization (WHO) estimated that "1 in 3 people, or 2.4
billion, are still without sanitation facilities" while 663 million people still lack access to safe and
clean drinking water. (WHO, 2017). In 2017, this estimate changed to 2.3 billion people without
sanitation facilities and 844 million people without access to safe and clean drinking water.
Inadequate WASH services and practices are also a major concern in health care facilities. For
example, a recent multicounty review representing 101 health care facilities in 54 low- and
middle-income countries revealed that 38% of health care facilities do not have any water
source, 19% do not have improved sanitation and 35% do not have water and soap for hand
washing (WHO/UNICEF, 2015). This suggests that there are huge gaps and urgent needs to
ensure that health care facilities are equipped to provide safe and good quality services to the
care and safety our children. Several international development agencies assert that attention to
WASH can also improve health, life expectancy, student learning, gender equality, reduce illness
and death and also reduce poverty and improve socio-economic development. Lack of sanitation
contributes to about 700,000 child deaths every year due to diarrhea, mainly in developing
countries. Chronic diarrhea can have long-term negative effects on children, in terms of both
physical and cognitive development. Bill & Melinda (2015). In addition, lack of WASH facilities
can prevent students from attending school, impose an unusual burden on women and reduce
work productivity. (UNICEF, 2015)

WASH in Nigeria
Nigeria ranks second in the world for having the greatest number of children under five
suffering from stunted growth - 10.3 million, or 33% of children under five. WHO (2015).
Nearly 45,000 children under the age of five in Nigeria die from diarrheal diseases caused by the
nation’s poor levels of access to water, sanitation and hygiene (UNICEF, 2015)
In Nigeria, Access to water supply was 67% and access to sanitation facilities was 41% as of
2013. An estimated 100 million Nigerians still lack basic sanitation facilities and 63 million do
not have access to improved source of drinking-water. In rural areas, only about 42% of
households have access to safe water. (UNICEF, 2018). Poor access to improved water and
sanitation in Nigeria remains a major contributing factor to high morbidity and mortality rates
among children under five. According to Michael (2016) children’s health and future potential
are compromised when they have no choice but to grow up without clean water, decent toilets
and good hygiene practices. Even if children survive their dangerous early years, repeated bouts
of diarrhea early in life are likely to leave them stunted. Nigeria is a party to the United Nations
Declaration of the Right to Water, which entitles every one living in Nigeria to sufficient,
affordable, safe and acceptable water for personal and domestic uses. Thus, Nigeria did not meet
the MDG target of 75% coverage for improved drinking-water and 63% coverage for access to
sanitation facilities by the year 2015.
The primary responsibility for the provision of domestic water supply is that of the state and
local governments. However, the federal government often intervenes to increase access in order
to meet these targets.

Under-nutrition among Children

Under- nutrition is the underlying cause of 45 percent of child deaths each year. Black et. al.
(2013) The term mal-nutrition covers three primary anthropometric measures: stunting, which is
low height for age; wasting, which is low weight for height; and underweight, which is low
weight for age. Despite targeted and comprehensive nutrition-specific interventions, the
persistent presence of mal- nutrition has caused a renewed focus on underlying causes that go
beyond lack of nutrients. Bhutta et al (2008). Inadequate access to clean water and unsafe
sanitation and hygiene practices increase the risk of severe infectious diseases that can contribute
to under nutrition. There are three key pathways by which lack of WASH access and practice
contribute to under nutrition. (Humphrey, 2014).
Lack of access to WASH can affect a child’s nutritional status in many ways. Existing evidence
supports at least three direct pathways: diarrheal diseases, intestinal parasite infections and
environmental enteropathy.

Diarrhea
 Diarrhea is a leading cause of mortality and morbidity among children under 5 years of
age. Although mortality from diarrhea in this age group has fallen steadily over the past decades
from 1.5 million deaths in 1990 to 622 000 deaths in 2012, diarrhea morbidity has remained
stable, with 1.7 billion cases occurring annually (Fischer Walker et al., 2012; Liu et al., 2012).
Children under 5 years of age in low-income countries experience on average 2.9 episodes of
diarrhea per year, with the highest incidence rates in the first 2 years of life – the critical window
for a child’s development (Fischer Walker et al., 2012).
Diarrhea and under nutrition form part of a vicious cycle. Diarrhoea can impair
nutritional status through loss of appetite, mal-absorption of nutrients and increased metabolism
(Caulfield et al., 2004; Petri et al., 2008; Dewey & Mayers, 2011). Frequent episodes of
diarrhoea in the first 2 years of life increase the risk of stunting and can impair cognitive
development (Grantham-McGregor et al., 2007; Victoria et al., 2008). At the same time,
undernourished children have weakened immune systems, which make them more susceptible to
enteric infections and lead to more severe and prolonged episodes of diarrhoea (Caulfield et al.,
2004).

Intestinal parasitic infections

Soil-transmitted helminthic infections – roundworm, whipworm and hookworm – affect
millions of people worldwide (WHO, 2013c). Soil-transmitted helminthic infections are directly
caused by poor sanitation. Helminthic eggs and larvae can survive for months in the soil and can
infect humans when ingested (e.g. via contaminated water or food), by contact with fomites or by
direct contact with the skin when walking barefoot on contaminated soil (hookworm larvae).
Soil-transmitted helminthic infections can affect nutritional status by causing mal-absorption of
nutrients, loss of appetite and increased blood loss. Heavy infections with whipworm and
roundworm can impair growth (O’Lorcain & Holland, 2000). Hookworm infections are a major
cause of anaemia in pregnant women and children. As many as one third of pregnant women in
Africa are at risk of hookworm-related anaemia (Brooker, Hotez & Bundy, 2008), which in turn
increases the risk of preterm delivery and low birth weight babies and, eventually, child under
nutrition (Black et al., 2013).

Environmental Enteropathy
The Enteric pathogens can impair nutritional status even in the absence of symptoms
such as diarrhoea. Children living in poor sanitary conditions are exposed to a high load of
pathogens, especially between 6 months and 2 years of age, when they start crawling on the floor
and putting objects into their mouths (Ngure et al., 2014). Chronic ingestion of pathogens can
cause recurring inflammation and damage to the gut, leading to mal-absorption of nutrients. This
condition is often referred to as environmental enteropathy or environmental enteric dysfunction
(Humphrey, 2014). Researchers suggest that environmental enteropathy may be an important
cause of poor growth and may compromise the efficacy of nutritional interventions (Humphrey,
2009; Korpe & Petri, 2012). Several reviews highlighting the mounting evidence for links
between unhygienic environments and gut dysfunction have recently been published ( Korpe &
Petri, 2012; Prendergast & Kelly, 2012).
Use of safe water, sanitation facilities, and good hygiene can improve nutritional
outcomes by addressing both immediate and underlying causes of malnutrition. Lack of
sanitation, in particular, is strongly correlated with acute malnutrition and stunting. Even in the
absence of diarrhea, a fecal-contaminated environment is linked to chronic under nutrition,
which reduces utilization of essential nutrients. Diarrheal disease reduces the absorption of
nutrients by the gut.
Under nutrition remains a significant public health threat that requires both WASH and
nutrition interventions. Under nutrition is an underlying cause of 45 percent of child deaths
globally, and the lives of nearly 7.4 percent of the world’s children are at immediate risk due to
severe wasting. Wasting is managed by specialized medical care combined with therapeutic
feeding (Black et al.,2013). In less developed countries, 26 percent of children under 2 years old
are stunted and will suffer permanent physical and cognitive effects. (Black et al.,2013). WASH
interventions are important component of programs that target stunting. Simple actions can help
prevent diarrhea and under nutrition, even in hygiene-challenged environments.
WASH can improve nutritional status in three ways:
1. WASH reduces the incidence of diarrheal disease. A recent study using the latest
burden of disease data estimates that almost 60 percent of diarrhea is caused by
unsafe water, lack of sanitation, and poor hygiene behaviors, and is thus
preventable (Prüss-Üstun et al. ,(2014). Extensive evidence supports the
hypothesis that persistent diarrhea increases the risk of under nutrition. A vicious
cycle exists between diarrhea and under nutrition, as children with diarrhea eat
less and are less able to absorb the nutrients from their food. At the same time,
they need additional calories to recover from the infection. Malnourished children
have weakened immunity and are more susceptible to diarrhea when exposed to
fecal matter from their environment. The World Health Organization (WHO)
estimates1.7billion cases of diarrheal disease annually, which leads to 9 percent of
child deaths (CHERG, 2013).
2. A second effect of poor WASH conditions is intestinal worm infection. Severe
whipworm and round worm infections are negatively associated with growth, and
intestinal worms may result in poor absorption of nutrients, thus affecting
nutritional status. WASH promotes nutrition status of children.
3. WASH interventions are able to reduce the pathogen load observed in
environments with poor WASH conditions. Some causes of under nutrition are
not directly associated with diarrhea, but instead are associated with high
pathogen environments and poor WASH conditions (Prüss-Üstun et al. (2014).
Although this cause of under nutrition is not well understood, its association with
high pathogen environments suggests that it may be caused by recurring
infections in the gut that limit the proper absorption of calories and nutrients. This
hypothesis is often referred to as environmental enteropathy or environmental
enteric dysfunction.

Water, Sanitation and Hygiene (WASH) and Nutrition

Over the past two decades, the world has made remarkable progress in children’s survival
and health: child deaths have been reduced by half. This is the result of years of effort and the
delivery of a small set of proven health and nutrition interventions. Despite this progress, each
year nearly six million children still die before their fifth birthday, most of these deaths are
preventable. Globally, the leading causes of death in children under five are preterm birth
complications, pneumonia, complications during labour and delivery, diarrhoea and sepsis or
meningitis. Progress has been uneven and millions of children have been left behind due to
poverty, their ethnic identity, because they live in remote areas or urban slums, or in countries
caught up in conflicts.
Within the health and nutrition thematic area, Save the Children WASH focusses on ensuring
that all young children receive the health and nutrition care and services they require to survive
through collaboration with local governments, multilateral institutions, grassroots organizations
and others to strengthen health systems, and works with individuals, families and communities to
encourage the uptake of healthy behaviors.

The Effect of lack of WASH on Child’s health

The effects of lack of appropriate water facilities, hand washing, and hygiene practices on
child health outcomes. Impaired cognitive learning and learning performance are long-term
outcomes of the negative effects of infections such as diarrhea, worm infestations, and
dehydrations which are largely attributed to poor water, sanitation, and hygiene conditions.
(Waddington 2017). Diarrheal incidences in children during their first few years of life have
been shown to limit their growth by about 8cm and cause an IQ point reduction when they
progress to about 7 or 8 years of age. Studies have shown that about 75% of all school absences
are illness related. Information regarding absenteeism from middle and higher income countries
has shown that poor academic and social development, high dropout rates, and reduced learning
performance are attributed to school absence in children (UN 2010)

Best Practices
WASH practices have been proven to reduce diarrheal rates by 30–40 percent (Cairncross et
al.,2010).This level of reduction are achieved through a comprehensive approach, promoting
improvements in key WASH practices(e.g., hand washing, treatment and safe storage of
drinking water, safe disposal of feces, and food hygiene);improving access to safe water and
sanitation. Furthermore, a clean environment for children is also important to reduce
exposure to the pathogenic surroundings. The best practices include:
A. Optimal Handwashing
Hand washing prevents diarrhea effectively when done properly and at critical times
(before preparing food eating, or feeding; after defecating, cleaning a baby, or changing a
diaper). Proper technique includes using soap, or an effective substitute such as ash,
rubbing hands together at least three times, rinsing hands in flowing water, and drying them
on a clean cloth or by air. A meta-analysis of hand washing studies conducted in
developing countries concluded that hand washing can reduce the risk of diarrhea in the
general population by42 percent. (Luby et al.,2011).
B. Treatment of Safe Drinking Water in Households
Treatment and safe storage of drinking water in households has been shown to reduce the
risk of diarrheal disease by 30–40 percent. Simple, low-cost strategies can greatly reduce
the microbial content of water and diarrheal disease morbidity reductions comparable to
those achieved by hand washing and sanitation. However, compliance is a major obstacle
to getting the correct and consistent use that is required to have a public health impact.
Treating water in the home can be done in several ways: chlorination; boiling; solar
disinfection (SODIS)via heat and UV radiation; filtration with different types of filters; and
combined chemical coagulation, flocculation, and disinfection .All treated water must be
stored in a clean and appropriate vessel with a narrow neck and a tap and/or lid. Access to
 water treatment supplies and willingness to pay for water quality(when households are
often paying very high rates for any water at all)also affect compliance with correct use.
C. Sanitation
Improved sanitation is a proven intervention to reduce diarrheal disease rates by as much
as one-third .However, sanitation remains a low priority for governments and donors due
to the lack of political will and the high cost of improvement. As one of the great
challenges in development and as Clean Water and Sanitation is one of the Sustainable
Development Goals, sanitation requires new focus and emphasis.
D. Key Food Safety Actions
The World Health Organization (WHO) published a document called 5 Keys to Safer Food
that describes actions families should take in the kitchen to maintain safe food.
They are:
 Wash hands before food preparation and feeding
 Handle food safely (e.g. reheat food before serving infants)
 Treat and safely store water for all individuals and especially for young children who eat
complementary foods and drink water
 Remove animal and human faeces from environment (e.g. dispose of infant faeces safely)
 Build and use latrines, engaging with WASH actors for technical support.

These actions are especially important during child weaning. Furthermore, high quality food
hygiene may contribute to a healthier intestinal micro biome and positively affect gut function.

The synthesis report of the recent UN post-2015 global thematic consultation on food security
and nutrition directly highlighted the role of safe drinking water, sanitation and hygiene in
enabling good nutrition. The report calls for combining access to adequate WASH with other
measures, such as ensuring a diversified diet, to eliminate stunting, wasting and underweight in
children.

BARRIERS TO ACCESSING BASIC SANITATION AND HYGIENE

The barriers to improving sanitation are complex and interrelated while the main problems are:
 A lack of political will and budgetary priority: governments have little interest in dealing
with sanitation issues.
 Poor policy on sanitation at state and federal level.
 Responsibilities for sanitation are fragmented and poorly coordinated among the state and
federal agencies.
 Inadequate and poorly used financial resources,
 Inability to promote or improve on the existing services.
 Low prestige and recognition on promoting sanitation and hygiene education.

Solution to Barriers
Achieving Sustainable Development Goal 6 by 2030 requires extraordinary efforts.
Based on World Bank estimates, Nigeria will be required to triple its budget or at least allocate
1.7 per cent of the current Gross Domestic Product to WASH. The ambition is highest for rural
sanitation where the gap for improved services is 64.1 per cent. Funding for the sub-sector is
weak, and significant household contribution is needed to eliminate open defecation despite low
family incomes. Data in the area of financing are difficult to come by, as most agencies are
usually reluctant to release accurate data. However, there are plans in place to guide the
channeling of funds for WASH activities, although the funds available for WASH are meager
compared to the requirements. The structures required for adequate management are equally in
place and they have the capacity to absorb any financial improvement in the sub-sector.
Achieving more equitable provision of WASH services in Nigeria will require re-directing the
little available resources to focus more on provision of WASH facilities in rural areas and the
need to continue to subsidize the services in rural areas.
Efforts are presently directed to the promotion of sanitation and improved hygiene in rural areas
as evidenced by the increased promotion activities of the NTGS and development partners

Conclusion
There is good evidence that poor WASH contributes to the majority of the burden of
diarrhea and related adverse health effects, and strong consensus around this point. There is
suggestive evidence that hygiene (i.e. hand washing) substantially reduces diarrheal diseases in
the community. There is suggestive evidence that sanitation and household water treatment can
reduce diarrhea. There is suggestive evidence that increasing water quantity directly reduces the
risk of diarrhea and other WASH-related diseases.
Therefore, all WASH programmes and all nutrition programmes should at least promote
hand washing. For people to adopt hand washing habits, sharing knowledge is not enough,
appropriate and specific behaviour change methodologies are necessary.

Recommendations
 Hygiene-related activities contribute just as much to reducing stunting as nutrition-
specific activities, therefore, all WASH programmes and all nutrition programmes should
at least promote hand washing. Everyone should have safe water, sanitation and hygiene
at home and ensure that children wash their hands often.
 All schools and health facilities should have safe water, sanitation and hygiene to prevent
the spread of infection among children.
 Water, sanitation and hygiene are sustainable and inequalities in access should be
progressively eliminated.
 Ensure sustainability of water services in rural and urban communities.
 Universal access to WASH is essential for tackling poverty, hunger, ill-health and
inequality, therefore, it should be wholeheartedly embraced by all.
 Achieving and sustaining universal access to WASH must depends on
establishing accountable systems for equitable and sustainable management of water
resources
 Provision of equitable access to water, sanitation and hygiene services. 
 Strengthen tailored community approaches to total sanitation including Community-Led
Total Sanitation (CLTS) in rural, urban and riverine settings.
 Strengthen local, state and national bodies’ capacity to develop and implement equitable
and sensitive WASH policies, strategies and guidelines.
.

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