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

Muhammad Nadeem,1 Mumtaz Anwar,2 Shahid Adil,3 Wajid Syed,4 Mahmood Basil A Al-Rawi,5 Ayesha Iqbal6,7 1Department of Economics, University of Education, Lahore, Vehari Campus, Pakistan; 2School of Economics, University of the Punjab, Lahore, Pakistan; 3Punjab Resource Improvement and Digital Effectiveness (PRIDE) Project, Planning and Development Board, Government of the Punjab, Punjab, Pakistan; 4Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 5Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; 6Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham UK; 7Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence: Muhammad Nadeem, Email muhammad.nadeem@ue.edu.pkBackground: Access to safe drinking water, sanitation, and hygiene (WASH) facilities is crucial for health and human rights, impacting nutrition and weight.Methods: Multiple Indicators Cluster Survey (MICS) 2017– 18 has been used in this study to examine the association between WASH and underweight, alongside other factors. Analysis included descriptive statistics, association tests, logistic regression, and population-attributable fractions (PAF).Results: According to results child were 1.8, 1.1 and 1.04 times less likely to be underweight if they had access to improved source of drinking water, improved sanitation and hygiene facilities respectively. The likelihood of child being underweight reduces by 1.4, 1.89, 2.01 and 2.55 times if the household wealth status increases from poorest to second, middle, fourth and richest wealth quintiles, respectively. As the mothers’ education level increases from no schooling to primary, middle, secondary, and higher level, the possibility of child being underweight reduces by 1.22, 1.24, 1.60 and 2.01 times, respectively. Moreover, the likelihood of a child being underweight decreases as the education level of the household head improves. If maternal age is less than 20 or more than 35 years the likelihood of the child being underweight is increased by 1.074 and 1.121 times, respectively. A child is 1.1 times more likely to be underweight if birth spacing is less than 2 years. A child’s risk of being underweight decreases by 1.1 times if they have not experienced diarrhea. A child who has never been breastfed has 1.3 times higher risk of being underweight. The results of Population Attributable Fraction (PAF) indicate that holding the other factors constant, approximately 36.46% burden of underweight was preventable by access to improved drinking water, sanitation, and hygiene practices.Conclusion: Comprehensive strategy is needed that focuses on improving access to safe drinking water, sanitation infrastructure, and hygiene behaviors.Keywords: water, sanitation, hygiene, children, underweight, Pakistan, WASH