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The causes of undernutrition are often linked to inappropriate complementary feeding practices and poor households’ access to water, sanitation and hygiene (WASH), but limited evidence exists on the combined effect of poor WASH and inappropriate complementary feeding practices on stunted child growth. We assessed the independent and joint contribution of inappropriate complementary feeding and poor WASH practices to stunted growth among children aged 6-23 months in the Jirapa Municipality of Ghana. A community-based cross-sectional analytical study design was used with a sample of 301 mothers/caregivers having children aged 6-23 months. The results indicate that in a multivariable logistic regression model that adjusted for confounders, children receiving both unimproved water and inappropriate complementary feeding had a higher and significant odd of becoming stunted (adjusted odds ratio = 33. 92; 95 % confidence interval 3 04, 37 17; P = 0 004) compared to households having both improved water sources and appropriate complementary feeding practices. Except for unimproved drinking water sources, poor sanitation and hygiene, which comprised the use of unimproved household toilet facilities, washing hands without soap and improper disposal of child faeces were not associated with the risks of stunting among children aged 6-23 months. The combined effect of unimproved water and inappropriate complementary feeding on stunting was greater than either unimproved water only or inappropriate complementary feeding only.
The present study was carried out in Jirapa District which is mainly rural and located in the north western corridor of the Upper West Region of Ghana. It lies roughly between latitudes 10⋅25° and 11⋅00° North and longitudes 20⋅25° and 20⋅40° West. It occupies 6⋅4 % of the regional landmass, representing a territorial size of 1188⋅6 square km. The district is mainly agrarian and farming serves as the main source of economic activity as the majority (82⋅7 %) of the households have agriculture as their main occupation, while the few are engaged in trading and formal employment. Many households are food secured from October to March (i.e. the harvesting period). There is one rainy season from May to October. Crops cultivated are mainly maize, guinea corn, millet, beans, groundnuts and bambara beans. Most of the women are involved in peasant farming with a cross-section of them combining that with pito brewing for the sake of family upkeep. The majority of the households depend on boreholes for water. However, for those who rely on the unimproved water, 94⋅1 % do not treat their drinking water. The rate of open defaecation among households is quite high as about 81⋅0 % of the households do not have toilet facilities in their homes (GDHS, 2014). An analytical community-based cross-sectional design was carried out from 25 November 2019 to 22 December 2019. The sample size was determined by using a single population proportion formula with the following assumptions: 23⋅0 % prevalence of the main outcome variable (i.e. prevalence of stunting) from a previous study in the area(12), 95 % confidence interval (CI) and 5 % margin of error. A sample size of 301 was estimated after considering 10 % of unexpected events (e.g. damaged/incomplete questionnaire) was factored in the sample size determination. Children aged 6–23 months and their mothers/caregivers were recruited for the study using a multistage sampling procedure. A stratified sampling procedure was used to stratify the sub-districts where each of the seven sub-districts constituted a stratum. A simple random sampling procedure was used to select the communities within each stratum using the Emergency Nutrition Assessment (ENA) sampling software. A comprehensive list of all households that constituted the sample frame was compiled from selected communities/clusters, and the systematic sampling techniques were used to select the study households. In the selection of the study participants in each household for the interview, only one eligible mother–child pair was selected using a simple random sampling. To assess the independent and joint effects of improved complementary feeding practices and WASH, we classified households in the following way: (1) households meeting the WASH criteria (i.e. safe disposal of child faeces, use improved drinking water source, availability of improved toilet facility and handwashing with soap); (2) household feeding children with appropriate complementary feeding practices and (3) households meeting WASH + appropriate complementary feeding practices. Appropriateness of complementary feeding practice and WASH status were the key independent variables, while child growth was the dependent variable. The data were collected from the mothers/caregivers using a structured questionnaire which was administered through face-to-face interviews at the household level. The data included socio-demographic and economic characteristics of the participants, young child feeding practices, child’s age, gender, mothers’ educational level, child illness in the past 2 weeks, birth spacing, utilisation of prenatal care, WASH practices, and mother and child anthropometric measures. Stunted child growth was defined as low length-for-age z-scores (LAZ < minus 2 standard deviations of the median)(13). Other child growth indicators measured were weight-for-length Z-score (WLZ) and weight-for-age Z-score (WAZ). A brief description of the main independent and dependent variables is as follows. Anthropometric measurements were taken by the researchers and trained field assistants. The length and weight were taken using standardised procedures.The length of the children less than 24 months was measured with an infantometer in a recumbent position to the nearest 0⋅1 cm. The weight of children was taken with minimal clothing using a digital SECA 890 digital scale to the nearest 0⋅1 kg. Anthropometric measures were then converted to indicators of LAZ, WAZ and WLZ as per the World Health Organization guidelines(14). Complementary feeding practice was assessed using a composite indicator comprising three of the WHO core IYCF indicators which were determined based on the 24 h dietary recall of mothers(15): timely introduction of solid, semi-solid or soft foods at 6 months, minimum meal frequency (MMF) and minimum dietary diversity (MDD). MDD was defined as the proportion of children aged 6–23 months of age who received foods from five or more food groups. The eight foods aregrains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin-A rich fruits and vegetables; other fruits, and vegetables; and breastmilk(16). MMF is defined as the proportion of breastfed and non-breastfed children aged 6–23 months, who receive solid, semi-solid or soft foods (but also including milk feed for non-breastfed children) the least number of times or more. The least number of times or more (i.e. two times for breastfeeding infants within aged 6–8 months, three times for breastfeeding children within 9–23 months and four times for non-breastfeeding children aged 6–23 months, within 24 h). Meals may include extraordinarily rich nutritious snacks and must be devoid of trivial quantities, and the frequency should be based on the caregiver report. Minimum acceptable diet (MAD) was defined by the WHO as the proportion of children aged 6–23 months who received both MDD and MMF during the previous 24 h(15). Appropriate complementary feeding practice was thus defined in the present study to comprise timely introduction of complementary foods at 6 months and meeting MAD(17–19). A child was thus classified as having received appropriate complementary feeding if he/she met all the following three criteria: complementary feeding started at the sixth month of birth, meeting MDD and MMF was adequate for the age of child. A score of 1 was assigned for meeting each of the criteria and zero for not. The summative score for the appropriate complementary feeding practice score comprised scores for MMF + MDD + timely introduction of complementary foods. Complementary feeding practice was treated as a categorical variable and classified as appropriate if the mother fulfilled the three practices as recommended. Complementary feeding was inappropriate if any of the three criteria was not met. WASH practices assessed included access to and use of safe drinking water, availability of sanitation facilities (e.g. latrines) and hygiene practices (e.g. handwashing with soap at critical times). Respondents were asked the method used to dispose of the youngest child's stool; the responses were categorised as ‘Safe’ or ‘Unsafe’. Disposal of faeces was classified as ‘Safe’ if the child is helped to use a toilet or latrine or faecal matter is disposed into a toilet or latrine. All other methods were considered ‘Unsafe’. Based on the criteria set by the Joint Monitoring Programme (JMP) for Water and Sanitation(20,21), improved water sources including protected wells, boreholes, piped water to houses or rainwater and unimproved water sources were defined as drinking water from an unprotected spring or well or surface water. Improved sanitation facilities are those designed to hygienically separate excreta from human contact and these include wet sanitation technology (flush and pour-flush toilets connected to sewers, septic tanks or pit latrines) and dry sanitation technology (ventilated improved pit latrines, pit latrines with slabs or composting toilets). Unimproved sanitation facilities were pit latrines without a slab, bucket latrines, bush or no facilities(21). A household wealth index, which is a composite measure of a household's cumulative living standard, was used as a proxy indicator for the socio-economic status (SES) of households. Principal component analysis was used to determine the household wealth index from information collected on housing quality (floor, walls and roof materials), source of drinking water, type of toilet facility, the presence of electricity, type of cooking fuel and ownership of modern household durable goods and livestock (e.g. bicycle, television, radio, motorcycle, sewing machine, telephone, cars, refrigerator, DVD/CD player, bed, computer and mobile phone)(22–25). These facilities or durable goods are often regarded as modern goods that have been shown to reflect household wealth. A household of zero index score, for example, means that the household has not a single modern good. The scores were thus added up to give the proxy household wealth index. Statistical Package for the Social Sciences (SPSS) Version 21 (SSPS Inc. Chicago, IL, USA) software was used for data entry, cleaning and analysis. The nutritional indicators of the child were computed using the Anthro Plus which converted anthropometric measures into z-scores. The various z-scores were transferred to the SPSS software for further analysis. Missing data and wrong entries were checked by generating frequency tables after the data entry. Univariate and multivariable logistic regression analyses were performed to identify determinants of stunting. Only variables that showed significant association (P 5 is an indication that multicollinearity may be present, while VIF > 10 is certainly multicollinearity among the variables. We did not have any VIF exceeding 5, indicating no collinearity. Crude and adjusted odds ratios (AORs) and their corresponding 95 % CIs were used to measure the strength of the association between stunting and its predictors. The Nagelkerke R2 value provides an indication of the amount of variation in the dependent variable explained by the model. The potential confounding factors of stunting that were measured and tested were: age of the child, educational status of the mother/caregiver, maternal height, number of children under 2 years in the household, household wealth index, knowledge of complementary feeding practices and antennal clinic attendance. The School of Allied Health Sciences, University for Development Studies, Ghana approved the study protocol. After providing the needed information and explanation, informed written consent was obtained from the participants. In situations, where the participants were illiterates, verbal informed consent was sought. Participants were provided copies of the signed forms for their records.
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