The sanitation-child malnutrition nexus in India

Childhood malnutrition remains one of the most pressing health challenges in India, affecting millions of children under the age of five. Despite notable progress in economic development and targeted health interventions, malnutrition indicators such as stunting, wasting, and underweight continue to plague the country.

A comprehensive spatiotemporal study by Lovely Jain et al., conducted from 1998 to 2021, provides critical insights into the association between child growth failure (CGF) indicators and household sanitation practices in India. This article summarizes the findings and explores their implications for policy and intervention strategies.

The complex landscape of malnutrition in India

Child malnutrition in India reflects a paradox: while the country has made significant strides in economic growth, it still suffers from some of the highest rates of malnutrition globally. Stunting, wasting, and underweight indicators provide a window into this persistent challenge. The study’s analysis of the National Family Health Surveys (NFHS) reveals a mixed trajectory.

The NFHS, conducted in multiple rounds (1998-1999, 2005-2006, 2015-2016, and 2019-2021), is a comprehensive survey capturing a wide range of health and demographic data across India. These surveys employed stratified random sampling techniques to ensure national and state-level representativeness, enabling the tracking of long-term trends in child health indicators. The analysis highlighted the following trends:

• Stunting: Decreased from 44.9% in 1998 to 35.5% in 2021. This decline reflects efforts to address chronic malnutrition, yet the prevalence remains alarmingly high in certain states.

• Underweight: Declined from 46.7% to 32.1% over the same period, suggesting progress in combating inadequate nutrition and weight deficiencies.

• Wasting: Increased from 15.7% to 21%, highlighting an alarming rise in acute malnutrition. This increase points to episodic food insecurity and public health emergencies that disproportionately affect vulnerable children.

Spatial trends and regional disparities

The study identifies significant geographical variations in CGF indicators across India. Hotspot regions—districts with high prevalence of stunting, wasting, and underweight—include states such as Bihar, Uttar Pradesh, Jharkhand, Madhya Pradesh, Rajasthan, Gujarat, and Odisha. In contrast, states like Kerala, Tamil Nadu, and Himachal Pradesh consistently exhibit lower malnutrition rates. These spatial patterns reflect disparities in access to healthcare, sanitation, education, and economic resources.

The role of sanitation in malnutrition

One of the study’s key findings is the strong association between improved sanitation facilities and reductions in stunting, wasting, and underweight prevalence. Improved sanitation, including access to proper toilets and clean water, reduces exposure to fecal pathogens that cause diarrhea and intestinal infections—common contributors to malnutrition.

Key observations

• Positive impact of improved sanitation: Districts with better sanitation facilities showed significantly lower rates of stunting and underweight children. Improved sanitation breaks the cycle of infection and malnutrition by reducing the transmission of waterborne and soil-transmitted diseases. Chronic exposure to these pathogens, particularly during early childhood, impairs nutrient absorption and stunts growth.

• Hotspot clusters: Hotspots for poor sanitation align with malnutrition hotspots, reinforcing the link between sanitation and child growth failure. This alignment underscores the necessity of geographically targeted sanitation improvements in regions with high malnutrition rates.

• Temporal progress: The percentage of households with improved sanitation increased from 29.2% in 1998 to 70.3% in 2021, paralleling declines in malnutrition rates in many regions. However, the progress remains uneven, with rural and economically disadvantaged areas still struggling to achieve adequate sanitation coverage.

• Behavioral changes: Beyond infrastructure, behavioral changes, such as promoting handwashing and hygienic waste disposal practices, play a crucial role in amplifying the benefits of improved sanitation. Community-based awareness campaigns and education initiatives have been shown to enhance the effectiveness of sanitation programs.

• Swachh Bharat Abhiyan: Launched in 2014, this nationwide cleanliness campaign has significantly expanded access to toilets and reduced open defecation. However, the study highlights gaps in usage and maintenance, indicating that sustained efforts are needed to ensure long-term health benefits.

By addressing both physical infrastructure and behavioral aspects, sanitation programs can more effectively combat the complex interplay of factors contributing to child malnutrition. The integration of sanitation improvements with nutrition and health initiatives offers a holistic approach to breaking the cycle of malnutrition.

Socioeconomic and maternal factors

The study highlights the importance of socioeconomic and maternal factors in mitigating malnutrition:

• Maternal education: Higher levels of maternal education were consistently associated with better nutritional outcomes. Educated mothers are more likely to adopt healthier feeding and childcare practices.

• Wealth index: Wealthier households had lower rates of malnutrition, emphasising the role of economic stability in ensuring food security and healthcare access.

• Caste and ethnicity: Historically marginalised groups, including Scheduled Castes and Scheduled Tribes, exhibited higher malnutrition rates, reflecting systemic inequities.

Trends over time

The spatiotemporal analysis reveals several critical trends:

Stunting and underweight: These indicators show a steady decline across most regions, suggesting that interventions targeting these issues have had some success. Programs such as the Integrated Child Development Services (ICDS) and POSHAN Abhiyaan have likely contributed to this decline by improving maternal and child nutrition awareness and providing supplementary nutrition. However, the progress remains uneven, with certain states and districts exhibiting persistently high rates due to socio-economic disparities and lack of targeted efforts.

Wasting: The increasing prevalence of wasting, a marker of acute malnutrition, underscores the need for immediate interventions addressing food insecurity and public health emergencies. This rise is linked to short-term nutritional deficits and health crises, such as epidemics and natural disasters, that disproportionately affect vulnerable populations. Emergency response strategies must prioritize therapeutic feeding programs and improved access to healthcare in high-risk areas.

Urban vs. rural disparities: Urban areas generally exhibit better nutritional outcomes compared to rural regions, reflecting disparities in infrastructure and healthcare access. Urban regions benefit from better sanitation, healthcare facilities, and awareness programs. In contrast, rural areas continue to face challenges such as limited healthcare access, lower education levels, and reliance on traditional practices that may hinder effective nutritional practices.

Regional variations: Some states, such as Kerala and Tamil Nadu, have successfully managed to lower malnutrition rates through robust public health systems and targeted welfare programs. On the other hand, states like Bihar, Jharkhand, and Uttar Pradesh still struggle with high malnutrition rates due to inadequate infrastructure, low literacy levels, and limited healthcare services. Understanding these regional differences is crucial for designing state-specific interventions that address the unique challenges of each region.

Gender disparities: Female children in certain regions are more likely to suffer from malnutrition due to cultural biases and gender-based discrimination. These disparities highlight the need for programs that specifically address the nutritional and healthcare needs of girl children, ensuring equitable access to resources.

Policy and programmatic implications

The findings have far-reaching implications for policymakers and healthcare providers:

Targeted interventions in hotspots: Hotspot districts identified in the study should be prioritised for interventions. Programs addressing both acute (wasting) and chronic (stunting, underweight) malnutrition must be tailored to regional needs, focusing on the underlying socio-environmental factors.

Strengthening sanitation and WaSH programs: Improving Water, Sanitation, and Hygiene (WaSH) facilities is critical to breaking the cycle of malnutrition. The Swachh Bharat Abhiyan initiative has made significant strides in expanding sanitation access, but gaps remain in rural and marginalised communities.

Integrating maternal education into nutrition programs: Investments in women’s education can have a transformative impact on child health. Programs that combine nutritional support with education and awareness campaigns for mothers can yield significant benefits.

Addressing acute malnutrition: The rise in wasting highlights the need for rapid response mechanisms during public health crises. Emergency nutrition programs, including therapeutic feeding and micronutrient supplementation, can help address this urgent issue.

Bridging urban-rural disparities: Rural regions require targeted investments in infrastructure, healthcare, and education to close the urban-rural gap in nutritional outcomes. Community-based healthcare models can play a pivotal role in delivering these services.

Challenges and limitations

While the study provides valuable insights, it also acknowledges certain limitations:

• Data gaps: The absence of district-level data for certain NFHS rounds limits the continuity of the spatial analysis.

• Cross-sectional design: The study’s design precludes causal inferences, necessitating longitudinal studies for a deeper understanding of malnutrition dynamics.

• Unmeasured factors: Community-level factors, such as healthcare facility availability, were not directly measured but likely influence nutritional outcomes.

Conclusion

The spatiotemporal analysis underscores that while progress has been made in reducing stunting and underweight prevalence, wasting remains a critical concern in India. The strong links between improved sanitation, maternal education, and better nutritional outcomes highlight the multifaceted nature of malnutrition and the need for coordinated, region-specific interventions. By addressing these underlying determinants, India can move closer to achieving its nutritional targets and ensuring a healthier future for its children.

Call to action

Policymakers, healthcare providers, and community leaders must collaborate to: (a) Prioritise sanitation and WaSH improvements in malnutrition hotspots (b) Expand maternal education and awareness programs (c) Address acute malnutrition through emergency response initiatives, and (d) Invest in infrastructure and healthcare in underserved regions. The path forward requires sustained commitment and innovative solutions, but the potential rewards—healthier children and a stronger, more equitable society—are well worth the effort.