The Association between Water, Sanitation, Hygiene, and Child Underweight in Punjab, Pakistan: An Application of Population Attributable Fraction

Figures & data

Figure 1 The interlinkages between water, sanitation and hygiene (WASH) and nutrition Adapted from MuraliCdharan (2019).The copyright permission has been obtained from the author, Arundati Muralidharan. Muralidharan A. The interlinkages between water, sanitation and hygiene (WASH) and nutrition. WaterAid India in Health, 9 August 2019. Available from https://www.wateraid.org/in/publications/the-interlinkages-between-water-sanitation-and-hygiene-wash-and-nutrition.¹⁵

Table 1 Descriptive Statistics

Variable	Description
Household Access to Improved Drinking Water	If drinking water is obtained from any of following sources, access to it is deemed improved and receives the value 1: Public Tap/Standpipe, Tube Well, Motorized Pump, Hand Pump (Mechanical), Dug Well: Protected Well, Spring: Protected Spring, Tanker-Truck, Cart with Small Tank/Drum/Cane, Water Kiosk, Piped Water into Dwelling, Piped to Compound/Yard, Piped to Neighbor, Bottled Water, otherwise it will be 0.
Household using Improved Sanitation Facilities	It is a binary variable that takes value 1 if any of following sanitary facilities are present: Pour flush or flush into a sewer pipe or septic tank. Pit Latrine, flush to Pit Latrine: Pit Latrine with Slab, Ventilated Improved Pit Latrine, and 0 otherwise.
Household observing Hygiene	It is a binary variable that takes value 1, if the household utilizes soap and water for handwashing and 0 otherwise, if no soap and water are available for handwashing.
Number of Household Members	It is a continuous variable and it ranges from 2 to 45.
Education Level of Household Head	Head of the household’s level of education is a categorical variable with values None/Preschool = 0, Primary = 1, and Secondary = 2. Lower = 1, Middle = 2, Upper = 3, and Higher = 4.
Household Wealth Status	A wealth quintile index of household possessions, assets, and amenities is constructed by principal component analysis after standardizing the variables and it is categorized as: Poorest = 1; Second = 2; Middle = 3; Fourth = 4, and Richest = 5.
Region	If respondent lives in an urban region, binary variable will assume value 1; otherwise, it will assume the value 2.
Gender of Child	It is a binary variable that assumes a value of 1, if child is a boy and a value of 0 if not.
Premature Birth	This variable has been measured on the basis of definition of preterm given by WHO, as “Preterm is defined as babies born alive before 37 weeks of pregnancy are completed”. So based upon this definition a binary variable has been constructed and it assumes a value of 1, if the birth occurred before 37 weeks of pregnancy and a value of 0 otherwise.
Mother’s Age	Mothers’ self-reported ages at childbirth divided into three categories: under 20, between 20 and 34, and 35 and above.
Birth Spacing	Birth spacing is the time from the prior live birth to the conception of the index pregnancy. WHO, (2006) recommends a birth-to-pregnancy interval of 24 months, for optimal maternal and neonatal outcomes. So this variable is categorized as less than 2 year, 2–3 years or older than 3 years.
Mother’s Education Level	Mother’s education level is a categorical variable with values as None/Preschool = 0, Primary = 1 Middle = 2, Secondary = 3, and Higher = 4.
Child Sickness	This is a binary variable that has been assessed as if child experienced diarrhea in the previous two weeks; otherwise, it assumes a value of 0.
Child ever been Breastfed	Assume 1, if Child has ever been nursed and 0 otherwise for this binary variable.
Underweight (Weight for Age)	Whether a child is underweight or not is a binary variable. Variable assumes value 1, if a child’s weight is less than −2 standard deviation for given age of given Z score as per WHO’s standard, and 0 otherwise. A child has been deemed underweight.

Note: Authors’ own calculations.

Table 2 Summary of Responses

Variable	Frequency	Percentage	Mean	Standard deviation
Underweight (Weight for Age)	Yes = 16,267; No = 57,256	Yes = 22.14; No = 77.86	0.221	0.415
Household access to Improved Drinking Water	Improved =72,400; Unimproved= 1123	Improved=98.47; Unimproved=1.53	0.015	0.123
Household using improved Sanitation Facilities	Improved= 54,619 Unimproved = 18,914	Improved=74.28 Unimproved=25.72	0.743	0.437
Household observing Hygiene	Yes= 57,154; No =16,369	Yes = 77.74; No =22.26	0.777	0.416
Number of Household Members	Number of household members varies from lowest number of households 2 to 45.	Number of household members varies from lowest number of households 2 to 45.	8.4	4.192
Education Level of Household Head	None/Preschool = 28,753; Primary = 14,235; Middle = 14,813; Secondary = 13,270; Higher = 6903	None/Preschool = 39.09; Primary = 19.36; Middle = 14.10; Secondary = 18.06; Higher = 9.38	1.393	1.395
Household Wealth Status	Poorest = 19,651; Second = 16,312; Middle = 14,813; Fourth = 13,159; Richest = 9588	Poorest = 26.73; Second = 22.17; Middle = 20.14; Fourth = 17.92; Richest = 13.05	2.684	1.375
Region	Urban= 18,439; Rural= 55,084	Urban= 25.10; Rural= 74.90	1.749	0.434
Gender of Child	Boy= 37,804; Girl= 35,719	Boy= 51.42; Girl= 48.58	1.486	0.5
Premature Birth	Yes= 5179; No=68,344	Yes = 7.04; No= 92.96	1.93	0.256
Mother’s Age	< 20 = 8049; 20–34 = 60,239; 35 and above = 5235	< 20 = 10.94; 20–34 = 81.93; 35 and above = 7.12	1.962	0.423
Birth Spacing	< 2 = 23,145; 2 = 22,131; 3 and above = 28,247	< 2 = 31.48; 2 = 30.10; 3 and above = 38.42	1.324	1.234
Mother’s Education Level	None/Preschool = 37,509; Primary = 14,254; Middle = 6630; Secondary = 8198; Higher = 6932	None/Preschool = 51.03; Primary = 19.38; Middle =9.02; Secondary = 11.14; Higher = 9.43	1.164	1.401
Child Sickness	Yes = 10,743; No = 62,780	Yes = 14.62; No = 85.38	1.854	0.353
Child ever been Breastfed	Yes = 44,732; No = 3045	Yes = 93.81; No = 6.19	1.062	0.241

Note: Authors’ own calculations.

Table 3 Association Between Underweight and Independent Variables

Variable	Pearson Chi2	Prob.
Water	30.212	0.000***
Sanitation	885.961	0.000***
Hygiene	580.583	0.000***
House hold member	323.017	0.000***
Education level of household head	844.472	0.000***
Household wealth status	2600	0.000***
Region	212.266	0.000***
Gender	2.200	0.138
Premature birth	20.518	0.000***
Mother’s age	44.059	0.000***
Birth spacing	97.619	0.000***
Mother’s education level	1800	0.000***
Child had diarrhea in last 2 weeks	109.292	0.000***
Child ever been breastfed	15.148	0.000***

Notes: Authors’ own calculations. Where ***p<0.01.

Table 4 Logistic Regression Results: Dependent Variable = Underweight

Variables	Dimension	Odd ratio.	St. Er.	t-value	p-value	95% Conf. Interval		Sig
Access to drinking water	Unimproved (base)
	Improved	0.567	0.062	−5.21	0.000	0.458	0.702	***
Sanitation	Unimproved (base)
	Improved	0.885	0.026	−4.23	0.000	0.836	0.936	***
Hygiene	No (base)
	Yes	0.961	0.027	−1.44	0.150	0.909	1.015
House hold member	Numbers	0.982	0.003	−6.48	0.000	0.977	0.987	***
Education level of household head	None/Preschool (base)
	Primary	1.065	0.032	2.07	0.038	1.003	1.130	**
	Middle	1.064	0.038	1.73	0.083	0.992	1.142	*
	Secondary	0.984	0.035	−0.45	0.656	0.918	1.055
	Higher	0.939	0.049	−1.20	0.230	0.847	1.041
Household wealth status	Poorest (base)
	Second	0.710	0.024	−10.36	0.000	0.665	0.757	***
	Middle	0.529	0.021	−15.87	0.000	0.489	0.573	***
	Fourth	0.497	0.023	−14.99	0.000	0.454	0.545	***
	Richest	0.392	0.024	−15.22	0.000	0.347	0.442	***
Region	Urban
	Rural	0.850	0.027	−5.09	0.000	0.799	0.905	***
Gender	Boy	1.043	0.023	1.88	0.061	0.998	1.090	*
	Girl (base)
Pre mature birth	Yes	0.955	0.043	−1.03	0.302	0.874	1.043
	No (base)
Mother’s age (years)	Less than 20	1.074	0.039	1.98	0.048	1.000	1.154	**
	20–34 (base)
	35+	1.121	0.049	2.59	0.009	1.028	1.222	***
Birth spacing	First birth (base)
	Less than 2 years	1.106	0.033	3.37	0.001	1.043	1.173	***
	2 years or more	1.045	0.031	1.49	0.137	0.986	1.107
Mother’s education level	None/Preschool (base)
	Primary	0.819	0.026	−6.27	0.000	0.769	0.872	***
	Middle	0.801	0.037	−4.79	0.000	0.732	0.877	***
	Secondary	0.622	0.031	−9.67	0.000	0.565	0.685	***
	Higher	0.496	0.031	−11.24	0.000	0.439	0.560	***
Child had diarrhea in last 2 weeks	Yes (base)
	No	0.902	0.026	−3.61	0.000	0.853	0.954	***
Child ever been Breastfed	Yes (base)
	No	1.274	0.057	5.38	0.000	1.166	1.391	***
	Constant	0.819	0.057	−2.87	0.004	0.715	0.939	***
	Mean dependent var		0.225	SD dependent var			0.418
	Pseudo r-squared		0.043	Number of obs			47,630.000
	Chi-square		2196.399	Prob > chi2			0.000
	Akaike crit. (AIC)		48,662.715	Bayesian crit. (BIC)			48,890.767

Notes: ***p<0.01, **p<0.05, *p<0.1 Authors’ own calculations.

Table 5 PAF of WASH of Being Underweight

	Mean/Ratio	S.E	Z	P-value	95% confidence Interval
Scenario 0	0.2210	0.0019	−173.06	0.000	0.2172	0.2248
Scenario 1	0.1404	0.0131	−20.93	0.000	0.1168	0.1687
PUF	0.6353	0.0592	−4.86	0.000	0.5291	0.7627
95% CI for PAF
		Estimate	Minimum		Maximum
PAF		0.3646	0.2372		0.4708

Muralidharan A. The interlinkages between water, sanitation and hygiene (WASH) and nutrition. WaterAid India in Health, 9 August 2019. Available from https://www.wateraid.org/in/publications/the-interlinkages-between-water-sanitation-and-hygiene-wash-and-nutrition. Accessed 19 May 2024.

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