Access to Water, Sanitation, and Household Hygiene, and the Nutritional Status of Children Under Five in Rural Areas

Authors

  • Ana Maria Fernandes Public Health Department, Universidade Oriental Timor Lorosa'e, Dili, Timor-Leste Author
  • Rosa dos Santos Public Health Department, Universidade Oriental Timor Lorosa'e, Dili, Timor-Leste Author
  • Aleixo de Jesus Public Health Department, Universidade Oriental Timor Lorosa'e, Dili, Timor-Leste Author
  • Beatriz Guterres Public Health Department, Universidade Oriental Timor Lorosa'e, Dili, Timor-Leste Author

DOI DOI

https://doi.org/10.64146/mg58af33

Keywords:

Child undernutrition, hygiene, sanitation, water supply

Abstract

Limited access to water, sanitation, and hygiene (WASH) is recognized as a contributing factor to child malnutrition, yet local empirical evidence from the rural mountainous areas of Timor-Leste remains scarce. This study examined the relationship between household WASH access and the nutritional status of children under five years of age in rural Lautém City. A community-based analytical cross-sectional study was conducted among 628 mother–child pairs in twelve sucos, using stratified cluster sampling between February and May 2024. Anthropometric indices were calculated using the 2006 World Health Organization (WHO) Child Growth Standards, and household WASH access was classified using the WHO/United Nations Children's Fund (UNICEF) Joint Monitoring Program service ladder. Associations were assessed using the chi-square test and multivariate binary logistic regression, reporting adjusted odds ratios (AOR) with 95% confidence intervals (CI) at a significance level of p < 0.05. Stunting, underweight, and wasting affected 51.0%, 33.4%, and 9.2% of children, respectively. After adjusting for maternal education, household wealth, and child age, unsafe drinking water (AOR = 1.84; 95% CI: 1.21–2.79), inadequate sanitation (AOR = 1.67; 95% CI: 1.14–2.45), and limited or no hygiene facilities (AOR = 1.59; 95% CI: 1.06–2.38) were independently associated with stunting; sanitation showed the most consistent association, while no indicator was associated with wasting. Inadequate household WASH conditions are strongly associated with stunting among rural children in Timor-Leste. Integrated, area-based sanitation and clean water programs, combined with maternal education and poverty alleviation, are needed to accelerate stunting reduction in Lautém.

References

Addae, H. Y., Sulemana, M., Yakubu, T., Atosona, A., Tahiru, R., & Azupogo, F. (2024). Household poverty and unimproved sanitation rather than complementary feeding indicators predict undernutrition among children in northern Ghana. PLOS ONE, 19(3), e0297698. https://doi.org/10.1371/journal.pone.0297698 DOI: https://doi.org/10.1371/journal.pone.0297698

Arief, Y. S., Yunita, F. C., Efendi, F., Murti, F. A. K., Pradipta, R. F., & McKenna, L. (2025). Determinants of stunting among children under five in Indonesia: A systematic review. JMIR Pediatrics and Parenting, 8, e68918. https://doi.org/10.2196/68918 DOI: https://doi.org/10.2196/68918

Bahwere, P., Judge, D. S., Spencer, P. R., Chiwile, F., & Mutunga, M. (2024). Prevalence and determinants of undernutrition among under-five children in rural Timor-Leste. PLOS ONE, 19(10), e0312433. https://doi.org/10.1371/journal.pone.0312433 DOI: https://doi.org/10.1371/journal.pone.0312433

Castillo, J. P., Molinaro, C. A., Pater, W. E., & Gautam, S. K. (2025). Water matters more: WASH determinants of child stunting in rural Mozambique. Children, 12(10), 1414. https://doi.org/10.3390/children12101414 DOI: https://doi.org/10.3390/children12101414

Dahir, H. M., Korse, A. H., & Mohamed, F. I. (2026). Determinants of child malnutrition in Somaliland: Evidence from the 2020 Demographic and Health Survey. Frontiers in Public Health, 13, 1734101. https://doi.org/10.3389/fpubh.2025.1734101 DOI: https://doi.org/10.3389/fpubh.2025.1734101

FAO, IFAD, UNICEF, WFP, & WHO. (2023). The state of food security and nutrition in the world 2023: Urbanization, agrifood systems transformation and healthy diets across the rural–urban continuum. FAO. https://doi.org/10.4060/cc3017en DOI: https://doi.org/10.4060/cc3017en

Gaffan, N., Kpozehouen, A., Degbey, C., Ahanhanzo, Y. G., & Paraíso, M. N. (2023). Effects of the components of water, hygiene and sanitation on the prevalence of stunting among children under five in Benin. BMC Nutrition, 9(1), 142. https://doi.org/10.1186/s40795-023-00751-8 DOI: https://doi.org/10.1186/s40795-023-00751-8

Hasan, M. M., Asif, C. A. A., Barua, A., Banerjee, A., Kalam, M. A., Kader, A., Wahed, T., Noman, M. W., & Talukder, A. (2023). Association of household WASH conditions with undernutrition among children under five in Bangladesh. BMJ Open, 13(6), e065330. https://doi.org/10.1136/bmjopen-2022-065330 DOI: https://doi.org/10.1136/bmjopen-2022-065330

Htet, M. K., Fahmida, U., Thurnham, D. I., Utomo, B., Ferguson, E., & Hadi, H. (2026). Environmental enteric dysfunction, IGF-1 and linear growth in Indonesian infants: A prospective cohort. Philosophical Transactions of the Royal Society B, 381(1950), 20250041. https://doi.org/10.1098/rstb.2025.0041 DOI: https://doi.org/10.1098/rstb.2025.0041

Jain, L., Pradhan, S., Aggarwal, A., & Padhi, B. K. (2024). Spatiotemporal patterns of sanitation access and child growth failure in India. JMIR Public Health and Surveillance, 10, e41567. https://doi.org/10.2196/41567 DOI: https://doi.org/10.2196/41567

Karlsson, O., Kim, R., Moloney, G. M., Hasman, A., & Subramanian, S. V. (2023). Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries. Maternal & Child Nutrition, 19(4), e13537. https://doi.org/10.1111/mcn.13537 DOI: https://doi.org/10.1111/mcn.13537

Kumari, D., & Kamal, B. (2026). Childhood stunting in high-burden Indian states: Socio-economic determinants and POSHAN Abhiyaan exposure. Jurnal Gizi dan Teknologi Pangan: Nutrismart, 2(2), 112–123. https://doi.org/10.64146/XPYQQC85 DOI: https://doi.org/10.64146/xpyqqc85

Lavanya, A., Rohan, I., Laksman, K., & Devan, A. (2026). Determinants of stunting in children aged 6–23 months in India’s highest nutritional burden states (Uttar Pradesh, Bihar, and Jharkhand). Jurnal Gizi dan Teknologi Pangan: Nutrismart, 2(2), 124–140. https://doi.org/10.64146/TBTKKT69 DOI: https://doi.org/10.64146/tbtkkt69

Lin, J., & Feng, X. L. (2023). Contribution of WASH and other determinants to the urban–rural disparity in child stunting in China. Maternal & Child Nutrition, 19(4), e13542. https://doi.org/10.1111/mcn.13542 DOI: https://doi.org/10.1111/mcn.13542

Lowe, C., Tsheten, T., Wagnew, F., Sarma, H., Ancha, A., Gray, D., & Kelly, M. (2026). Environmental enteric dysfunction biomarkers and child growth: A systematic review. Nutrition Research Reviews. https://doi.org/10.1017/S0954422425100231 DOI: https://doi.org/10.1017/S0954422425100231

Masset, E., & Sharma Waddington, H. (2025). Water, sanitation and hygiene interventions and child mortality and morbidity: A network meta-analysis. Nature Water, 3, 1070–1079. https://doi.org/10.1038/s44221-025-00484-x DOI: https://doi.org/10.1038/s44221-025-00484-x

Ministry of Health, & UNICEF. (2022). Timor-Leste food and nutrition survey 2020: Final report. Ministry of Health.

Mudadu Silva, J. R., Vieira, L. L., Murta Abreu, A. R., de Souza Fernandes, E., Moreira, T. R., da Costa, G., & Mitre Cotta, R. M. (2023). Water, sanitation, and hygiene vulnerability and stunting in children under five. Public Health, 219, 117–123. https://doi.org/10.1016/j.puhe.2023.03.024 DOI: https://doi.org/10.1016/j.puhe.2023.03.024

Mustika, S. (2025). The relationship of parenting and feeding practices with stunting in toddlers. Jurnal Gizi dan Teknologi Pangan: Nutrismart, 1(1), 65–75. https://doi.org/10.64146/21K9RN09 DOI: https://doi.org/10.64146/21k9rn09

Nomura, K., Bhandari, A. K. C., Matsumoto-Takahashi, E. L. A., & Takahashi, O. (2023). Factors associated with undernutrition among children under five in Timor-Leste. Annals of Global Health, 89(1), 63. https://doi.org/10.5334/aogh.4199 DOI: https://doi.org/10.5334/aogh.4199

Quamme, S. H., & Iversen, P. O. (2022). Prevalence of child stunting in sub-Saharan Africa and its risk factors. Clinical Nutrition Open Science, 42, 49–61. https://doi.org/10.1016/j.nutos.2022.01.009 DOI: https://doi.org/10.1016/j.nutos.2022.01.009

Sahiledengle, B., Petrucka, P., Kumie, A., Mwanri, L., Beressa, G., Atlaw, D., Tekalegn, Y., Zenbaba, D., Desta, F., & Agho, K. E. (2022). Association between water, sanitation and hygiene and childhood stunting in Ethiopia: A hierarchical analysis. BMC Public Health, 22(1), 1943. https://doi.org/10.1186/s12889-022-14309-z DOI: https://doi.org/10.1186/s12889-022-14309-z

Samuel, S., Retni, R., & Wulandari, W. (2026). The relationship between clean water quality and household sanitation with the incidence of diarrhoea in toddlers. HealthSmart: Jurnal Kesehatan Masyarakat, 2(1), 15–28. https://doi.org/10.64146/37NF3M92 DOI: https://doi.org/10.64146/37nf3m92

Sidik, A., Maulana, I., & Satria, T. (2025). The relationship between parenting patterns and education of mothers with child nutrition in families benefiting from the Family Hope Programme. HealthSmart: Jurnal Kesehatan Masyarakat, 1(1), 27–36. https://doi.org/10.64146/3WXR6X22 DOI: https://doi.org/10.64146/3wxr6x22

Soegijanto, S., Santoso, J. N., Eldyjoe, A. G., Halim, B. C. A., Sastra, T., Jossevynne, Z. E., Valentino, F., & Astina, J. (2025). Water, sanitation, and hygiene determinants of childhood stunting in Indonesia: A review. Indonesian Journal of Life Sciences, 7(1), 42–58. https://doi.org/10.54250/ijls.v7i1.201 DOI: https://doi.org/10.54250/ijls.v7i1.201

Som, S. V., Wieringa, F. T., Campos Ponce, M., Polman, K., Dakurah, P., Duncan, D., Blomberg, J., Rasphone, S., & van der Hoeven, M. (2023). Combined effect of WASH and infant and young child feeding on child stunting in Lao PDR. BMJ Open, 13(10), e073974. https://doi.org/10.1136/bmjopen-2023-073974 DOI: https://doi.org/10.1136/bmjopen-2023-073974

Downloads

Published

29-08-2026

Issue

Vol. 2 No. 2 (2026): August

Section

Articles

License

Copyright (c) 2026 Ana Maria Fernandes, Rosa dos Santos, Aleixo de Jesus, Beatriz Guterres (Author)

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Authors who publish with HealthSmart: Journal of Public Health agree to the following terms:

1. Authors retain copyright and grant the journal the right of first publication, with the work simultaneously licensed under a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0). This license allows others to share and adapt the work, provided appropriate credit is given to the author(s) and to the work's initial publication in this journal.
2. Authors may enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., posting it to an institutional repository or publishing it in a book), with an acknowledgement of its initial publication in this journal.
3. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges as well as earlier and greater citation of published work.

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License (https://creativecommons.org/licenses/by-sa/4.0/).

How to Cite

Fernandes, A. M., Santos, R. dos ., Jesus, A. de, & Guterres, B. . (2026). Access to Water, Sanitation, and Household Hygiene, and the Nutritional Status of Children Under Five in Rural Areas. Health Smart : Jurnal Kesehatan Masyarakat, 2(2), 90-106. https://doi.org/10.64146/mg58af33