Water, Sanitation, and Malnutrition in Pakistan: Challenge for Sustainable Devel..


Cite Us
Views (388)
Downloads (0)


Abstract

This paper aims to analyze the water, sanitation, and malnutrition situation in Pakistan and to evaluate the sustainable development goals situation. To find the association, this study applies a chi-square test utilizing a sample of 3,575 children of age less than five years, extracted from the data of Pakistan Demographic and Health Survey (PDHS) 2017-18. The results of chi-square show that underweight and stunting have a significant association with water and sanitation in Pakistan. Pakistan's progress in sustainable development goals is yet slow, especially targets of goal 3 and goal 6, which are far behind other countries of the region. The study concludes that there is a need to allocate more resources in programs such as water, sanitation, nutrition, and poverty reduction to uplift the socio-economic standard of the common folk.

                                                                                                                             

Key Words:

Malnutrition, Water, Sanitation, SDGs, PDHS, Pakistan

                                                                                                                           

Introduction


Malnutrition is a significant factor that contributes a lot to under-five child mortality in developing countries. The World Health Organization reports that 35% of deaths of children of age less than five years are because of malnutrition (Black et al., 2008). In low and middle-income countries, almost 20% of children under five are underweight, while 32% are with stunted growth, and one out of ten are wasted. (WHO/UNICEF 2010). Moreover, in South Asia and Southeast Asia, 50% of global maternal deaths are also reported (Bhutta et al, 2004).

The previous empirical work that has been done on determinants of child malnutrition have consensus that economic status or wealth status etc. remains the most significant determinant of malnutrition over the time till now (Akombi et al, 2019; Mistry et al, 2019; Nie et al, 2019; Frieda Sossi, 2019; Adhikari et al, 2019; Asim & Nawaz, 2018; Hasan et al, 2017; Karki et al, 2017; Pravana et al, 2017; Dhungana, 2017; Khalid et at, 2017; Rabbani et al, 2016; Rabbi & Karmaker, 2015). But most significantly many researchers found that improved water and sanitation are also significant determinants of malnutrition (Mistry et al, 2019; Pratim Roy, 2019; Nguyen et al., 2019; Sinha et al, 2018; Menon et al, 2018; Tariq et at, 2018; Cunningham et al, 2017; Rabbi & Karmaker, 2015) as well.

Improved sanitation is associated with better health outcomes. The share of polluted water and inadequate sanitation-related diseases in the global burden of diseases is nearly 10% (Prüss-Üstün et al, 2007). Globally, half of the maternal-child underweight problem is due to inadequate sanitation, poor hygiene, and polluted water (World Bank 2008; Victora et al, 2008). So, malnutrition not only occurs due to lack of nutrition, but it also occurs due to social deprivation (poor water and sanitation) as well. Investing in social wellbeings like water and sanitation is not only improves the social status of individuals but also contributes to poverty reduction. Providing improved water and sanitation help in uplifting the social status or living condition of a nation. Many researchers found that improved water and sanitation are significant determinants of malnutrition (Mistry et al, 2019; Pratim Roy, 2019; Nguyen et al, 2019; Sinha et al, 2018; Menon et al, 2018; Tariq et al, 2018; Cunningham et al, 2017; Rabbi & Karmaker, 2015).

 Pakistan has unified sustainable goals into its national agenda for development. A study by Brollo & Hanedar (2021) concluded that Pakistan’s progress in water and sanitation is below the median of those countries whose per capita GDP is below 3,000 US Dollars, and to reduce the water and sanitation gap, Pakistan would need US 55 billion Dollars which accounts 2 percent of GDP every year till 2030. This study is on two accounts. First, this study assessed the latest SDGs situation of water and sanitation of Pakistan and also compared with SAARC countries to see the progress of Pakistan. There is very limited literature in Pakistan which discuss the water and situation progress in sustainable development goals. Secondly, the study utilized the latest data, Pakistan demographic and health survey 2017-18 and observed the association between water and sanitation indicators with child malnutrition. To our best knowledge, this is the latest study using the latest national data, which correlates water and sanitation with child nutritional status for Pakistan. Most importantly, the results of the study may be used in identifying the gaps in public policy solutions for achieving the SDGs targets.  

 

Methods

Data

This paper utilized a sample of 3,575 children of age less than five years extracted from the latest data, PDHS 2017-18. This data provides wide information on nutrition and demographic characteristics, women and children nutritional and healthcare information, women empowerment, domestic violence, etc. this study used anthropometric measurements of eligible under-five children.

 

Measures

According to WHO (2009), three indices in the form of a z-score are used to measure child malnutrition. These three indices are stunting, wasting, and underweight. These indices are further coded in binary form, “1” if the child is stunting, wasting, or underweight otherwise “0”. While water and sanitation variables are further categorized in two categories (improved, unimproved). Upgraded water sources and developed sanitation services are kept in the improved category, and in the same way, undeveloped water resources and unimproved sanitation services are considered in the unimproved category.


Table 1. Recoding Sanitation Variables

Improved

Unimproved

Flush toilet

Flush/dispense flush to a piped sewerage system

Flush to the sewage-disposal tank

Flush to a pit toilet

Pit toilet latrine

Ventilated improved pit latrine (VIP)

Pit toilet with slab

Compositing toilet

Pit toilet without a slab or open toilet

Any facility shared with other households

Mobile toilet

Hanging latrine

Flush to somewhere else

Flush, I don’t know where

No service

No service/bush/field/stream/river

Other unimproved

Source: Authors using PDHS data

 

Table 2. Recoding Drinking Water Variables

Improved

Un-Improved

Tap water

Household tap water

Tap water into a plot

Public pipe water

water from electric tube well

Borehole

Protected well of water

Shielded spring and rainwater

Filtration plant

Piped to neighbor

Uncovered dug well

Protected well

Polluted spring

Tanker truck

Open water

River/stream/pond/lake/dam/canals

water cart having a small reservoir

Bottled/sachet water

Other polluted

Source: Authors using Pakistan DHS data

 


Analysis

To measure the association of water and sanitation with child malnutrition, the study applied a chi-square test using STATA statistical software.

 

Results and Discussion

The results of the Pakistan Demographic and Health Survey shows that stunting prevalence is 38%, under-weight 23%, and wasting 8% among under-five children in Pakistan.

The results in table 3 of chi-square show that underweight and stunting are highly significant association with water and sanitation in Pakistan, while wasting has an insignificant relationship with water and sanitation.


 

Table 3. Association between stunting, wasting, underweight with water and sanitation

Indicators

Underweight

Stunting

Wasting

 

Chi-square Value

P-value

Chi-square Value

P-value

Chi-Square Value

P-value

Water

3.768

0.052**

5.103

0.024**

0.145

0.703

Sanitation

7.743

0.005***

21.61

0.000***

0.061

0.805

Significance level: ***p value < 0.01, **p value < 0.05, *p value < 0.1, p values are based on 2 -test

Source: Author’s estimations

 


The Situation of Child Health Indicators, Water, and Sanitation

The malnutrition status of children is measured through HAZ, WAZ, and WHZ. The mortalities are in children occur due to the worse situation of these indicators. The causes of making these indicators worse are mostly socio-economic conditions, more spatially water and sanitation conditions. Below in tables and graphs is the overall discussion on children’s health indicators, mortalities, and water and sanitation in Pakistan with comparison to SAARC countries in the region.


 

Table 4. Pakistan’s Situation in Child Mortality Rates; Comparison within Region (SAARC)

Country

Neonatal deaths per 1000 live births

Infant deaths per 1000 live births

Under-five deaths per1000 live births

Afghanistan

22

45

55

Bangladesh

28

38

46

India

30

41

50

Maldives

11

18

20

Nepal

21

32

39

Pakistan

42

62

74

Source: DHS SAARC

Graph 1: Child Mortality Rates

Source: Author’s estimation (SAARC DHS data)

 


Graph 1 shows the child mortality rates for SAAC countries are given in Table 4. The graph depicts the highest neonatal, infant, and under-five mortalities in Pakistan and the lowest in the Maldives.


 

Table 5. Pakistan’s Situation in Malnutrition Prevalence; Comparison with Region (SAARC)

Country

Stunting

Wasting

Underweight

Afghanistan

Variables missing

 

 

Bangladesh

36.5%

14%

32.5%

India

38%

21%

36% NFHS-4

Maldives

15%

9%

15%

Nepal

36%

10%

27%

Pakistan

38%

8%

23%

Source: DHS SAARC

Graph 2: Child Malnutrition Prevalence

Source: Author’s estimation (SAARC DHS data)

 


Graph 2 sketches the situation of child anthropometric rates for SAAC countries given in Table 5. The graph explains that the stunting rates are high in Pakistan, Bangladesh, India, and Nepal, while the Maldives lie at the bottom among countries. Wasting rates are slightly higher in India that are 21%, than in other countries, while Pakistan remains at the bottom in wasting among SAARC. The rates of underweight are higher in Bangladesh and India, while the Maldives stood at the bottom in underweight.


 

Table 6. Pakistan’s Situation in Water and Sanitation; Comparison within Region (SAARC)

Country

Access to

drinking water

Not-Access to

drinking water

Access to

Toilet facility

Not-Access to Toilet facility

Afghanistan

65%

45%

25%

75%

Bangladesh

97.6%

2.4%

68.7%

31.3%

India

90%

10%

48%

52%

Maldives

98%

2%

98%

2%

Nepal

95%

5%

62%

48%

Pakistan

95%

5%

70%

30%

South Asia

92%

8%

45%

55%

World

91%

9%

67%

33%

Source: DHS SAARC and UNESCAP-2015

 


Table 6 explains the water situation in SAAC. The graph shows that almost all SAARC countries except India have 95% to above access to water while India has 90% access to water access. All SAARC countries have less than 6% not-access to water, while India has 10% not-access to water. While this percentage shows only access to the water source, not the water quality.


Graph 3: Access to Water

Source: Author’s estimation (SAARC DHS data)

 


Graph 3 explains the water situation in SAAC given in Table 6. The graph shows that almost all SAARC countries except India have 95% to above access to water while India has 90% improved water access. All SAARC countries face less than 6% unimproved water, while India faces 10% unimproved water.


Graph 4: Access to Sanitation Facility

Source: Author’s estimation (SAARC DHS data)

 


Graph 4 explains the toilet facility situation in SAAC given in Table 6. According to the graph, Maldives have ideal access to a toilet facility. In this context, Pakistan and Bangladesh are slightly better. While others have a worse situation in access to toilet facility which is less than the half. While in case of not-access to the toilet facility, Maldives lies at the top while India is on the bottom.

 

Achievements in Sustainable Development Goals

On the eve of Millennium Development Goals in 2015, All 193 Member countries and states of the UN General Assembly made a unanimous agreement for “Transforming our world: the 2030 Agenda for Sustainable Development (the 2030 Agenda)”. This Agenda 2030 is an action plan for global prosperity and peace.

 

Targets

SDG (Goal-1) states the end of extreme poverty, measured by the number of people living below $1.25 per day, from the globe by 2030, while part-b of goal-1 says to decrease all dimensions of poverty for all age group people at least by half till 2030. SDG (Goal-3) targets the reduction of maternal mortality rate (MMR) ˂ 70% /1000 lives globally by 2030, while part-b of goal-3 states that by 2030, reduce the avoidable mortality ratio of infants to as low as 12 out of 1000 live births and decrease child mortality (children of age less than five years) to 25 out of 1000 live births. SDG (Goal-6) targets to attain global and equal access to clean drinking water by 2030, while part-b of goal-6 states the attainment of improved sanitation and hygiene and ending of open defecation globally by 2030.

The progress in (Goal 3) is not up to the mark, but it is progressing in a positive direction slowly, according to a report of Asia Pacific on SDGs progress (2019) that the South and South-West Asia sub region’s progress level is far ahead than other sub-region leads other sub-regions in the areas of health and wellbeing (Goal 3). On the other hand, progress in accessing clean water and sanitation is not in the right direction (Goal 6). Access to clean water, improved sanitation, and sufficient energy are basic elements for sustainable sustenance, but till 2015 only 45% of the population of South Asia had availability of clean water and sanitation, which implies that almost 960 million people had no access to sanitation and 610 million people were practising open defecation (UNESCAP-2018).

According to table 4, in the achievement of SDGs goals, the progress of SAARC is very slow; no country has achieved any goal out of these three except the Maldives in only neonatal mortality targets, but it is very close to achieving the (Goal 6). In Goal 3, SAARC's progress is slow but in a positive direction.


 

Table 7. Pakistan Situation in Achievements of SGDs; Comparison with Region (SAARC)

 

Sustainable Development Goals

Afghanistan

Bangladesh

India

Maldives

Nepal

Pakistan

SDG Goal-1: Reduce poverty at least by 50% of people of all ages living in a poverty

Population living in poverty at $1.25 per day in 2005 Purchasing Par Parity (% of the population)

 

43.3

23.6

1.5

23.7

12.7

Proportion of Population living below the national poverty line

35.8

31.5

21.9

15.7

25.2

29.5

SDG Goal-3: Reduce MMR to <70, Neonatal and Infant mortality <12, Under 5-year mortality < 25

Maternal mortality rate measured as deaths /100,000 live births

396

176

174

68

258

178

Newborn mortality rate measured as deaths / 1,000 live births

22

28

30

11

21

42

Child mortality rate measured as deaths /1,000 live births

45

38

41

18

32

62

Child (of the age less than five years) mortality rate measured as deaths /1,000 live births

55

46

50

20

39

74

SDG Goal-6: Achieve access to properly clean water and sanitation for all and eradicate defecation in an open place

Access to improved water sources (% of population)

65

97

90

98

95

95

Access to improved sanitation (% of the population)

25

68.7

48

98

62

70

Source: UNESCAP report September-2018 based on ESCAP Database and official source, SAARC DHS.

 


Improved Water and Sanitation and Child Health

Improved sanitation and water facility are highly correlated with good health. In vast literature, the water, sanitation, and health nexus has been documented (Montgomery and Elimelech 2007). A study by Cohen et al, (2017) for 194 developing countries from the group of low- and middle-income countries expressed that improved water and sanitation facilities result in decreasing child mortality ratio. Moreover, the studies on the region of South Asia and Sub-Sahara Africa also elucidate the similar association between child health and improved water and sanitation facility. Clean water for drinking and good sanitation facility directly or indirectly results in lowering mortality, morbidity, and malnutrition among children of age under five years (Anand & Roy, 2016)

Further, Harding et al, (2018) examined the determinants of wasted growth among children under five in South Asia and concluded that gender, birth order, illiteracy of mother, the short stature of mother, poor economic status of household are the significant factors determining wasted growth. Research elucidated that WASH is responsible for child development at an early stage by reducing the probability of being stunted and anaemic (Ngure et al, 2014). A study by Benova et al, (2014) examined the relationship between water and sanitation facility on maternal mortality and concluded that improper water and sanitation facility was related to increased maternal mortality.

A study by WHO calculated that 34% of diseases burden among children is associated with poor environmental conditions (Prüss-Üstün & Corvalán 2007). Polluted water, improper sanitation facilities, not washing hands, and poor hygiene are the primary factors defining poor environmental conditions in determining the health of society.  Drinking water and sanitation facilities are among the few environmental risk factors that can be altered using proper technology and an adequate amount of funding (Rehfuess et al, 2009). Current studies estimated that almost one and a half million children decease every year due to contaminated water, improper hygiene, and insufficient sanitation facilities (UNICEF 2010). Unavailability of clean drinking water and improper sanitation is the major factor contributing to diarrhea and related diseases in children (Gamper-Rabindran et al, 2007). Diarrhoea-related diseases are responsible for almost 19% of global child mortality (Boschi-Pinto et al, 2008). The death rate in children is found to be significantly reduced after providing piped water and improving sanitation (DaVanzo 1988; Gamper-Rabindran et al, 2007). Many other studies also concluded that improved water and sanitation significantly determine a reduction in mortality compared to other social, economic, and health indicators (Shi, 2000).

Less research has been done specifically on water and sanitation, mother and child malnutrition nexus. Evidence does exist that establishes a link between unclean water and improper sanitation and infectious diseases (Esrey et al, 1985). Studies also show a strong causal relationship between these infectious diseases and increased malnutrition (Bartlett, 2003). Esrey (1996) suggested that child nutritional status could be improved by providing access to clean water at a level that is optimal in combination with adequate sanitation. Wibowo & Tisdell (1993) also found that improved sanitation had a stronger effect on morbidity than clean water in a study of communities in Central Java, Indonesia.

 

Cost-benefit of Improving Water and Sanitation for Health

Hutton (2007) conducted a study to analyze the costs and benefits of interventions made for improving water and sanitation. This study found that in developing countries, a US$1 investment in water and sanitation returns up to US$46.  The major factor was time-saving which contributes almost 80% of the economic benefits resulting from improved water and sanitation services.

Cost-benefit analyses of interventions made in water and sanitation facilities reveal that such investments result in a handsome number of returns. Hutton & Haller (2004) conducted a study for the WHO and found that the returns of investment amount US$1 on water and sanitation facility are ranging from US$5 to US$28 in many developing countries.  The most prominent reason for such benefits is the time saving associated with good sanitation and water facility. It also included there are direct as well as indirect benefits of decreased morbidity and mortality and reduction in the incidence of diarrheal diseases. The direct benefits include the financial savings that came from a reduction in health care expenditures, and indirect benefits are reaped as there would be fewer absentees from work or school due to sickness. Their study estimates that provision of water and sanitation services to each person in the world who is currently without would cost US$22.6 billion, or US$10.7 per person in the developing world per year. This intervention would yield, they estimate, US$262.8 billion in economic benefits. The research was conducted by considering diarrhoea and related diseases only to study the impact of water and sanitation on health. By considering the disease associated with malnourishment could also help in estimating the total health benefits of interventions in the water sanitation system (Hutton & Haller 2004).

 

Conclusion

The results of chi-square show that underweight and stunting are significantly associated with water and sanitation in Pakistan, while wasting has an insignificant relationship with water and sanitation. Pakistan still has not achieved SGD goal 3 and goal 6 targets and for behind from other SAARC countries in the region. The effort to undertake this study was to identify the effective public policy solutions for combating child and maternal mortalities and morbidities, which are 1) investment in nutrition and 2) investment in social development such as water and sanitation programs. Investment in nutrition is fundamental for children's growth. While investment in water and sanitation programs means saving the health cost in terms of water and sanitation borne diseases as well as water and sanitation wise societal discrimination. There is a need to increase finance and prioritize the development budget in water and sanitation programs effectively to uplift the living standard of the population.


 

 


 


Graph 1
Graph 2
Graph 3
Graph 4

Adhikari, R. P., Shrestha, M. L., Acharya, A., % Upadhaya, N. (2019). Determinants of stunting among children aged 0-59 months in Nepal: findings from Nepal Demographic and Health Survey, 2006, 2011, and 2016. BMC Nutrition, 5(1), 1-10. DOI: https://doi.org/10.1186/s40795- 019-0300-0

Akombi, B. J., Chitekwe, S., Sahle, B. W., % Renzaho, A. (2019). Estimating the double burden of malnutrition among 595,975 children in 65 low-and middle-income countries: a meta- analysis of demographic and health surveys. International journal of environmental research and public health, 16(16), 2886. DOI: https://doi.org/10.3390/ijerph16 162886

Asim, M., % Nawaz, Y. (2018). Child malnutrition in Pakistan: evidence from literature. Children, 5(5), 60. DOI: https://doi.org/10.3390/children 5050060

Anand, A., % Roy, N. (2016). Transitioning toward sustainable development goals: The role of household environment in influencing child health in Sub- Saharan Africa and South Asia using recent demographic health surveys. Frontiers in public health, 4, 87. DOI: 10.3389/fpubh.2016.00087

Brollo, F., % Hanedar, E. (2021). Pakistan: Spending Needs for Reaching Sustainable Development Goals (SDGs). IMF Working Papers, 2021(108). DOI: https://doi.org/10.5089/978151358239 9.001

Benova, L., Cumming, O., % Campbell, O. M. (2014). Systematic review and meta‐analysis: association between water and sanitation environment and maternal mortality. Tropical medicine % international health, 19(4), 368-387. DOI: https://doi.org/10.1111/tmi.12275

Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., ... % Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The lancet, 371(9608), 243-260. DOI: https://doi.org/10.1016/S0140- 6736(07)61690-0

Boschi-Pinto, C., Velebit, L., % Shibuya, K. (2008). Estimating child mortality due to diarrhoea in developing countries. Bulletin of the World Health Organization, 86, 710-717. https://www.who.int/bulletin/volume s/86/9/07-050054.pdf?ua=1

Bhutta, Z. A., Gupta, I., de'Silva, H., M Roy har, D., Awasthi, S., Hossain, S. M., % Salam, M. A. (2004). Maternal and child health: is South Asia ready for change?. Bmj, 328(7443), 816-819. DOI: https://doi.org/10.1136/bmj.328. 7443.816

Bartlett, S. (2003). Water, sanitation and urban children: the need to go beyond "improved" provision. Environment and Urbanization, 15(2), 57-70. DOI: http://eau.sagepub.com/content/ 15/2/57.

Cunningham, K., Headey, D., Singh, A., Karmacharya, C., % Rana, P. P. (2017). Maternal and Child Nutrition in Nepal: Examining drivers of progress from the mid-1990s to 2010s. Global Food Security, 13, 30- 37. DOI: https://doi.org/10.1016/j.gfs.201 7.02.001

Cohen, R. L., Murray, J., Jack, S., Arscott-Mills, S., % Verardi, V. (2017). Impact of multisectoral health determinants on child mortality 1980-2010: An analysis by country baseline mortality. Plos one, 12(12) e0188762. DOI: 10.1371/journal.pone.0188762

Dhungana, G. P. (2017). Nutritional status and the associated factors in under five years children of Lamjung, Gorkha and Tanahun districts of Nepal. Nepalese Journal of Statistics, 1, 15-18. DOI: https://doi.org/10.3126/njs.v1i0. 18814

DaVanzo, J. (1988). Infant mortality and socio-economic development: Evidence from Malaysian household data. Demography, 25(4), 581-595. DOI: http://www.jstor.org/stable/206 1323.

Esrey, S. A. (1996). Water, waste, and wellbeing: a multicounty study. American journal of epidemiology, 143(6), 608-623. DOI: http://aje.oxfordjournals.org/con tent/143/6/608.abstra

Esrey, S. A., Feachem, R. G., % Hughes, J. M. (1985). Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities. Bulletin of the World Health organization, 63(4), 757. DOI: http://www.ncbi.nlm.nih.gov/p mc/articles/PMC2536385/.

Gamper-Rabindran, S., Khan, S., % Timmins, C. (2009). The impact of piped water provision on infant mortality in Brazil: A quantile panel data approach. Journal of Development Economics 92, 188-200. DOI: http://www.nber.org/papers/w1 4365.pdf.

Harding, K. L., Aguayo, V. M., % Webb, P. (2018). Factors associated with wasting among children under five years old in South Asia: Implications for action. PloS one, 13(7), e0198749. DOI: https://doi.org/ 10.1371/journal.pone.0198749

Hasan, M., Sutradhar, I., Shahabuddin, A., % Sarker, M. (2017). Double Burden of Malnutrition among Bangladeshi Women: A Literature Review. Cureus, 9(12), e1986. DOI: https://doi.org/10.7759/cureus.1 986

Hutton, G., Haller, L., % Bartram, J. (2007) Economic and health effects of increasing coverage of low-cost household drinking-water supply and sanitation interventions to countries off-track to meet MDG target 10. Geneva: World Health Organization. https://apps.who.int/iris/bitstream/ha ndle/10665/69684/WHO_SDE_WSH_ 07.05_eng.pdf

Hutton, G., Haller, L., Water, S., % World Health Organization. (2004). Evaluation of the costs and benefits of water and sanitation improvements at the global level (No. WHO/SDE/WSH/04.04). World Health Organization. http://www.who.int/water_sanitation _health/wsh0404/en/.

Karki, D. K., Bose, D. K., Singh, B. K., Gupta, N., % Khanal, P. K. (2017). Determinants of Malnutrition Under 5 Years Children-A Cross Sectional Study in the Palpa District of Nepal. https://www.researchgate.net/publica tion/313875726_Determinants_of_M alnutrition_Under_5_Years_Childre n_- _A_Cross_Sectional_Study_in_the_P alpa_District_of_Nepal

Khalid, N., Aslam, Z., Kausar, F., Irshad, H., % Anwer, P. (2017). Maternal malnutrition and its kick on child growth: an alarming trim for Pakistan. Journal Food Nutrition and Population Health, 1(3), 24. https://www.imedpub.com/articles/m aternal-malnutrition-and-its-kick-on- childgrowth-an-alarming-trim-for- pakistan.php?aid=21514

Mistry, S. K., Hossain, M. B., Khanam, F., Akter, F., Parvez, M., Yunus, F. M., ... % Rahman, M. (2019).Individual-, maternal-and household- level factors associated with stunting among children aged 0-23 months in Bangladesh. Public health nutrition, 22(1), 85-94. DOI: https://doi.org/10.1017/S136898 0018002926.

Menon, P., Headey, D., Avula, R., % Nguyen, P. H. (2018). Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from 2015-16. Maternal % child nutrition, 14(4), e12620. DOI: https://doi.org/10.1111/mcn.126 20

Montgomery, M. A., % Elimelech, M. (2007). Water and sanitation in developing countries: including health in the equation. Environmental science % technology, 41(1), 17-24. DOI: http://dx.doi.org/10.1021/es0724 35t.

Nguyen, P. H., Scott, S., Neupane, S., Tran, L. M., % Menon, P. (2019). Social, biological, and programmatic factors linking adolescent pregnancy and early childhood undernutrition: a path analysis of India's 2016 National Family and Health Survey. The Lancet Child % Adolescent Health, 3(7), 463-473. DOI: https://doi.org/10.1016/S2352- 4642(19)30110-5

Nie, P., Rammohan, A., Gwozdz, W., % Sousa-Poza, A. (2019). Changes in child nutrition in India: a decomposition approach. International journal of environmental research and public health, 16(10), 1815. DOI: https://doi.org/10.3390/ijerph16 101815

Ngure, F. M., Reid, B. M., Humphrey, J. H., Mbuya, M. N., Pelto, G., % Stoltzfus, R. J. (2014). Water, sanitation, and hygiene (WASH),environmental enteropathy, nutrition, and early child development: making the links. Annals of the New York Academy of Sciences, 1308(1), 118- 128. DOI: 10.1111/nyas.1233

Pratim Roy, M. (2019). Malnutrition in children and its determinants: a study from east India. Tropical doctor, 49(2), 113-117. DOI: https://doi.org/10.1177/0049 475518824825

Pravana, N. K., Piryani, S., Chaurasiya, S. P., Kawan, R., Thapa, R. K., % Shrestha, S. (2017). Determinants of severe acute malnutrition among children under 5 years of age in Nepal: a community-based case- control study. BMJ open, 7(8), e017084. DOI: http://dx.doi.org/10.1136/bmjop en-2017-017084

Prüss-Üstün, A., % Corvalán, C. (2007). How much disease burden can be prevented by environmental interventions? Epidemiology, 18(1), 167-178. http://www.ncbi.nlm.nih.gov/pubmed /16971860

Rabbani, A., Khan, A., Yusuf, S., % Adams, A. (2016). Trends and determinants of inequities in childhood stunting in Bangladesh from 1996/7 to 2014. International journal for equity in health, 15(1), 1- 14. DOI: https://doi.org/10.1186/s12939-016- 0477-7

Rabbi, A. M. F., % Karmaker, S. C. (2015). Determinants of child malnutrition in Bangladesh-A multivariate approach. Asian journal of medical sciences, 6(2), 85-90. DOI: https://doi.org/10.3126/ajms.v6i 2.10404

Rehfuess, E. A., Bruce, N., % Bartram, J. K. (2009). More health for your buck: health sector functions to secure environmental health. Bulletin of the World Health Organization, 87, 880- 882

Sossi, F. (2019). Prevalence and determinants of undernutrition in women in Nepal. Acta Scientific Nutritional Health, 3(5), 184-203. https://actascientific.com/ASNH/pdf/ ASNH-03-0268.pdf

Sinha, R. K., Dua, R., Bijalwan, V., Rohatgi, S., % Kumar, P. (2018). Determinants of stunting, wasting, and underweight in five high-burden pockets of four Indian states. Indian journal of community medicine: official publication of Indian Association of Preventive % Social Medicine, 43(4), 279. DOI: https://doi.org/10.4103/ijcm.ijcm_151 _18

Shi, Anqing. (2000). How access to urban potable water and sewerage connections affects child mortality. Development Research Group, World Bank. DOI: http://econpapers.repec.org/pap er/wbkwbrwps/2274.htm.

Tariq, J., Sajjad, A., Zakar, R., Zakar, M. Z., % Fischer, F. (2018). Factors associated with undernutrition in children under the age of two years: secondary data analysis based on the Pakistan demographic and health survey 2012-2013. Nutrients, 10(6), 676. DOI: https://doi.org/10.3390/nu10060 676

UNESCAP- SRO- SSWA SDG Report. (September 2018): Achieving the Sustainable Development Goals in South Asia: Key Policy Priorities and Implementation Challenges.

UNICEF. (2010). Progress for Children: Achieving the MDGs with Equity. New York: UNICEF. http://www.unicef.org/publications/fil es/Progress_for_Children- No.9_EN_081710.pdf.

Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., ... % Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: consequences for adult health and human capital. The lancet, 371(9609), 340- 357. DOI: https://doi.org/10.1016/S0140- 6736(07)61692-4

WHO/UNICEF Joint Monitoring Programme on Water Supply and Sanitation. 2010. "Progress on sanitation and drinking water 2010 update." WHO/UNICEF. 22, 2010. http://www.who.int/water_sanitation _health/publications/9789241563956/ en/index.html.

WHO. (2009). Child growth standards and the identification of severe acute malnutrition in infants and children: A Joint Statement by the World Health Organization and the United Nations Children's Fund. In WHO Press. https://www.who.int/nutrition/public ations/severemalnutrition/97892415 98163/en/

World Bank. (2008). Environmental Health and Child Survival: Epidemiology, Economics, Experiences. Environment and Development. Washington DC. http://hdl.handle.net/10986/6534

Wibowo, D., % Tisdell, C. (1993). Health, safe water and sanitation: a cross- sectional health production function for central Java, Indonesia. Bulletin of the World Health Organization, 71(2), 237-245. DOI: http://www.ncbi.nlm.nih.gov/p mc/articles/PMC2393453/.


Follow Us