Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia.
College of Nursing, University of Saskatchewan, Saskatoon, Canada.
BMC Public Health. 2024 Jun 3;24(1):1484. doi: 10.1186/s12889-024-18931-x.
Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia.
We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders.
Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of β = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (βindirect = 0.014, p < 0.001), wasting (βindirect = 0.009, p = 0.002), and underweight (βindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of βtotal = 0.285, p < 0.001.
Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.
在埃塞俄比亚，卫生条件差和/或露天排便仍是一个严重的公共卫生问题，而改善卫生设施的普及程度仍然有限。关于露天排便对儿童线性生长失败影响的文献越来越多。但是，关于露天排便对儿童贫血影响的研究却很少。在这项研究中，我们研究了在埃塞俄比亚 6-59 个月的儿童中，儿童营养不良（即发育迟缓、消瘦和体重不足）是否在露天排便与儿童贫血之间存在中介作用。
我们使用了埃塞俄比亚人口与健康调查的汇总数据（2005-2016 年），包括 21918 名（加权数据）6-59 个月大的儿童。贫血定义为 5 岁以下儿童经海拔校正后的血红蛋白（Hb）水平低于 11g/dl。儿童营养不良通过身高年龄 Z 评分（HAZ）、体重年龄 Z 评分（WAZ）和体重身高 Z 评分（WHZ）评估发育迟缓、消瘦和体重不足。使用 bootstrap 计算中介效应，当 95%bootstrap 置信区间（95%CI）不包含零值时，间接效应被认为具有统计学意义。此外，在调整潜在混杂因素后，使用分层回归分析分别探讨了露天排便与儿童贫血之间的统计学关联。
我们的分析显示，6 至 59 个月大的儿童中有近一半（49.6%）贫血，46.8%发育迟缓，9.9%消瘦，29.5%体重不足。此外，45.1%的儿童来自实行露天排便（OD）的家庭。露天排便与贫血相关（AOR：1.28；95%CI：1.18-1.39），并且通过 β=0.233（p<0.001）的直接效应正向预测贫血。儿童营养不良在 OD 和贫血之间的关系中起到部分中介作用。分析间接效应的结果显示，儿童营养不良显著中介了露天排便和贫血之间的关系（发育迟缓（β间接=0.014，p<0.001），消瘦（β间接=0.009，p=0.002），体重不足（β间接=0.012，p<0.001））。当考虑到儿童营养不良的中介作用时，露天排便对贫血的总效应为 β总=0.285（p<0.001），有积极影响。
露天排便对贫血有显著的直接影响。儿童营养不良显著中介了 OD 和贫血之间的关系，进一步放大了这种影响。这一发现具有重要的计划意义，呼吁在埃塞俄比亚加强、加速和大规模实施消除露天排便和普及卫生设施的战略。
