Governance of water, sanitation and hygiene (WASH) in South Africa and Associations with nutritional status in children between birth and one year of age

Momberg, Douglas J.
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Background: The realisation that infant and childhood linear growth cannot be completely improved by optimized diet and reduced diarrhoea has led to the hypothesis that linkages between different forms of undernutrition and water, sanitation, and hygiene (WASH) factors, may contribute towards persistently poor child health outcomes. The policy environment in South Africa advocates for multi-sectoral approaches, with a number of policies being adopted over the past three decades in order to address WASH, and child growth and nutritional status. However, most indicators of early childhood nutritional status show disappointing results and efforts have not been sufficient to shift the prevalence of stunting still affecting a third of children under three years of age. Aim: The aim of this thesis is to examine the governance landscape of WASH, and links between WASH and nutritional status in early childhood. Methods: This thesis undertook 3 objectives, firstly a systematic review was conducted, surveying the literature linking WASH, childhood nutritional status and governance in sub-Saharan African settings. Secondly, through purposive sampling, mapping of the various departments and associated policies that are responsible, for the provision of WASH facilities, and for the nutritional status of children was conducted; in-depth policy review conducted of 3 key policies containing reference to children, WASH, and nutrition. Expert interviews, and a consensus development conference were conducted with experts at the intersection between WASH and nutrition. Thirdly, a longitudinal cohort study from birth to 1 year of age was designed to explore associations between WASH and nutritional status of children living in Soweto. At delivery, 156 mother-infant pairs, were recruited from Chris Hani Baragwanath Academic Hospital and followed-up weekly from birth to 6 months, and fortnightly from 6 months to 1 year, where anthropometric measurements and data pertaining to feeding practices, WASH, socio-economic status, and morbidity and illness were collected. Hierarchical regression analyses were used to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum. 16 Results: In sub-Saharan Africa, results from recent trials show disappointing results in the attempt to address infant growth and nutritional status through WASH. In addition, existing studies do not explore the role of governance of WASH in their design, nor describe if and how actors in the field of WASH are incorporated into the research process. In the context of Soweto, household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at ϭ month ;βс -2.24) and 6 months ;βс -Ϭ.ϵϲͿ; a decrease in WAZ at ϭ month ;βс -ϭ.ϮϭͿ, ϲ months ;βс -ϭ.ϱϳͿ, and ϭϮ months ;βс - 1.92); and finally, with WHZ scores at ϭϮ months ;βс -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at ϭ month for both HAZ ;βс Ϭ.ϱϯͿ and WAZ ;βс Ϭ.ϰϰͿ. Conclusion: The public sector would benefit from better integration of the concept of WASH into their policy, planning, and implementation frameworks, whereas too few WASH sector plans consider their impact on nutrition in children. More trials are needed to determine and evaluate which WASH interventions are effective at which stages in early childhood development. Provision of safely managed sanitation at household and community levels may be required before improvements in growth related outcomes are obtained, while continued efforts in the promotion of exclusive breastfeeding and provision of social support are integral to achieving local and international nutrition targets.
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2020