Evaluating the associations between WASH-related safety, maternal anxiety, and child nutritional status in informal settlements in Soweto

Abstract

Introduction: Violence against women has serious psychological consequences, which often lead to women experiencing depression, post-traumatic stress, anxiety, and suicidality Women and girls have been excessively affected by poor WASH infrastructure, affecting their physical health as well as their psychological health. In informal urban settlements, inadequate water, sanitation, and hygiene (WASH) infrastructure poses significant risks to the health and well-being of women and children. Women often experience heightened anxiety and perceived threats to their safety when accessing communal WASH facilities, which may compromise caregiving practices and, in turn, affect child health outcomes. Poor WASH facilities are generally linked to a multitude of health burdens, and particularly childhood morbidity, under-5 mortality, as well stunting. Maternal mental health plays a significant role in child nutritional status in so far as maternal anxiety may hinder adequate hygiene practices as well as maintenance of adequate personal and household hygiene, which may result in child illness. Child malnutrition affects physical growth, increases risk of morbidity and mortality, reduces physical work capacity, human capital, as well as cognitive development. While both WASH conditions and maternal mental health have independently been associated with child nutrition, the interrelated effects of WASH- related safety, maternal anxiety, and child nutritional status remain underexplored in low-resource settings. Aim: The aim of this study was to evaluate the associations between WASH-related safety, maternal anxiety, and child nutritional status in informal settlements in Soweto. Methods: This study has drawn on cross-sectional data from a larger controlled before-and- after intervention study. A baseline survey was conducted at recruitment to collect data on socio-economic and demographic characteristics, access to WASH facilities, as well as perceived safety and age, height, and morbidity levels. Data were collected for both the women (n=200) and children <5 years of age in the household. Anthropometric measurements were done children < 5 years, their heights (or lengths) measured in centimetres. The baseline assessment of this study took place 4 in August 2021, South Africa was placed on lockdown alert level 1 at the time due to the COVID-19/Coronavirus pandemic. Descriptive statistics were used to describe and summarize characteristics, bivariate associations were explored utilizing the appropriate statistical techniques given the variable type. Finally, results were integrated with a priori hypotheses of key associations to estimate a multi-variable regression model. Results: Most women had completed high school education (91.0%) and were single (73.1%). Child health indicators revealed a mean HAZ score of -0.69, with 54 children aged 0- 11 months and 107 aged 12-59 months. Women's mean age was 29.8 years, with a mean height of 157.2cm. WASH conditions showed limited access to piped water (1%), with most women relying on public taps (87%). Sanitation mainly consisted of portable toilets during the day (54.5%) and bucket/open defecation (28.5%). Perceived safety was low, with 91% feeling their neighbourhood was unsafe, and 86.5% reporting Nomzamo Park as unsafe. Safety was prevalent, with 72.5% feeling unsafe going to and from WASH facilities. A substantial proportion (32.5%) experienced moderate to high anxiety. Bivariate analyses found no significant association between women's anxiety and WASH characteristics or safety perceptions. However, child nutrition (HAZ score) was significantly associated with the type of water source and perceived neighborhood safety. Multivariate analyses revealed no significant association between maternal anxiety and WASH conditions or safety perceptions. However, child HAZ scores were significantly associated with perceived neighborhood safety and safety when accessing WASH facilities, indicating community characteristics' impact on child nutritional status. Conclusion: In informal settlements, limited access to clean water, sanitation, and hygiene facilities can lead to health issues, especially for mothers and children. Safety, or the lack thereof, in these areas worsens these problems and increases maternal anxiety, affecting caregiving practices and child nutrition. Socio-economic factors, like poor living conditions and lack of basic services, further impact maternal and child health. Child nutrition is closely tied to WASH conditions, with inadequate access contributing to malnutrition and poor health. Findings highlight the critical influence of environmental and perceived safety factors on child nutrition in informal settlements. 5 Although maternal anxiety was not directly associated with child HAZ scores, perceived community safety and night-time WASH access conditions were significant predictors. These findings underscore the need for integrated interventions that improve WASH infrastructure while also addressing the broader psychosocial and safety environments in which caregiving occurs. Researching these factors in places like Soweto is crucial for developing effective interventions to improve community health.