Nutrition In the News: Hygiene Matters

Imagine this – a young mother does all she can to care for her three year old child. She exclusively breastfed for the first six months, took her child to the nearby anganwadi for all essential vaccinations, and has enrolled her child in the anganwadi for pre-school education. But the child is sickly and the mother worried and confused that despite all her efforts, her child is underweight and small for his age. Do you know why?

A staggering 48.2 million (38.4%) young children under the age of five years in India are stunted, a condition that results from severe and persistent undernutrition. While poor nutrition is the primary cause, inadequate hygiene contributes to undernutrition among children, with half of all undernutrition cases estimated to be associated with diarrhoea and infections resulting from unsafe water and sanitation, and unhygienic behaviours. Repeated diarrhoea in the first two years of life directly contributes to a quarter of all cases of stunting. Good nutritional intake is undoubtedly critical for children’s growth and development;   hygiene behaviours are important disease prevention and health promotion strategies as well that have great potential to complement good nutrition. Handwashing with soap and water can help prevent diarrhoea, a prominent cause of sickness and death among children under age five globally and in India. In addition to health gains, hygiene behaviours can confer long-term economic benefits like the economic gains from decreased incidence of diarrhoea from handwashing with soap are significant. Annual net costs to India from not washing hands with soap after contact with faeces are estimated at USD 23 billion, and net returns from national behaviour change programmes aimed at handwashing are estimated to be USD 5.6 billion, at USD 23 per disability-adjusted life year (DALY) avoided.

Hygiene behaviours work by breaking the transmission of water and sanitation related diseases (Figure 1) via primary barriers that effectively separate faeces from human contact through safe disposal of excreta (i.e., by using toilets and safely disposing of child faeces), and remove faecal matter from hands after contact with excreta (i.e. by washing hands after defecation). Secondary barriers are hygiene behaviours that prevent faecal pathogens present in hands and the environment from increasing and reaching new hosts. These include handwashing before preparing food, eating and feeding infants and children; food hygiene; safe handling and storage of drinking water; and keeping household premises free from faecal contamination. The faecal-oral route suggests that to arrest faecal contamination, toilet use should be accompanied by other key hygiene behaviours, especially handwashing with soap and water.

A majority of nutrition interventions in India centre on nourishing children. To sustain these important nutritional benefits, interventions must incorporate attention to hygiene behaviours, particularly those that prevent harmful faecal pathogens from entering children’s bodies, and depleting and diverting nutrients essential for physical and cognitive growth. In this context, handwashing and safe disposal of child excreta are important. Children’s faeces have more harmful pathogens given the higher incidence of enteric infections among young children than among adults. Disposing a child’s stool appropriately by assisting the child to use the toilet, or discarding child’s faeces directly in the toilet reduces the risk of faecal matter being present in the child’s immediate environment. Handwashing with soap and water at critical times (after defecation, after cleaning a child’s bottom and disposing child faeces, before feeding infants/children, before eating and before food preparation) is estimated to reduce diarrhoeal diseases by 47%, having tremendous health benefits for children. 

Promoting and inculcating these hygiene behaviours for improved nutritional outcomes calls for a multi-sectoral and multi-modal approach within nutrition interventions that incorporates the following: 

1) Presence and location of functional water, sanitation and hygiene infrastructure in households and early child care facilities like anganwadis (e.g., child friendly toilets, water and soap facilities outside the toilet to wash hands after toilet use); 

2) Creating awareness about the importance of hygiene behaviours and links with desired health and nutritional outcomes among frontline workers (ASHAs, anganwadi workers) and caregivers in a household; 

3) Engendering and sustaining hygiene behaviours through well designed and focused behaviour change campaigns that target psychological drivers–nurture, disgust, affiliation and social status among caregivers; and

4) Using health and nutrition service delivery points to deliver hygiene messages to caregivers of young children.

The POSHAN Abhiyan, government’s overarching scheme for holistic nourishment, is an ideal opportunity to integrate water, sanitation and hygiene in simple yet powerful ways to achieve the goal of a malnutrition free India.