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Environmental sanitation and undernutrition among China’s children and adolescents from 1989 to 2011

Nature Water volume 1, pages 736–749 (2023)Cite this article

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Abstract

Research on the benefits of basic water and sanitation interventions for child linear growth faltering has had mixed success, which may mean more environmentally transformative interventions are needed. To help guide these efforts, we used panel data from China (1989–2011) to estimate the relationships between changes in household- and community-level water, sanitation and air pollution and changes in both child and adolescent height-for-age difference. Our regression analysis revealed community excreta levels as having an additional effect (estimated regression coefficient β = −0.87 cm) beyond households’ own toilet facilities (β = −0.28 cm), the latter involving risks of exposure to both human and animal faeces. We found some evidence of a community excreta threshold below which additional linear growth benefits may be limited. In communities with high levels of excreta, having high piped water coverage and a household toilet offered little protection. Polluting cooking fuel was the most influential exposure at the household level (β = −0.45 cm). According to our decomposition analysis, improvements in these four exposures collectively explain 15% of the decline in growth faltering in China during the study period.

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Fig. 1: Co-occurring changes in height and environmental sanitation.
Fig. 2: Province-level average stunting and household environmental sanitation.
Fig. 3: Community and household exposure effects.
Fig. 4: Explaining the observed change in HAD from 1991 t0 2011.
Fig. 5: Community sanitation threshold effects on HAD.

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Data availability

The publicly available CHNS individual and household data may be accessed at https://www.cpc.unc.edu/projects/china/data/datasets. The community data are not publicly available, as they contain information that could compromise research participant privacy. To obtain the community-level data, interested parties must receive permission from the CHNS. More information can be found at https://www.cpc.unc.edu/projects/china/data/datasets/cdatause. All figures in the main text were created using raw CHNS data. We also used GDP per capita in constant US$2015 data to construct a national wealth variable. These data are available for download at the World Bank Open Data website https://data.worldbank.org/indicator/NY.GDP.PCAP.KD.

Code availability

The code is available upon request from the corresponding author with permission from the CHNS to use the community-level data.

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Acknowledgements

The CHNS recognizes funding from the National Institutes of Health (NIH), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; R01 HD30880 and R01 HD38700), the National Institute on Aging (NIA; R01 AG065357), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; R01 DK104371 and P30 DK056350), the National Heart, Lung, and Blood Institute (NHLBI; R01 HL108427), the NIH Fogarty International Center (D43 TW009077) and the Carolina Population Center (P2 CHD050924 and P30 AG066615) since 1989. The CHNS is grateful for the support of the China–Japan Friendship Hospital, Ministry of Health for CHNS 2009, the Chinese National Human Genome Center at Shanghai since 2009 and the Beijing Municipal Center for Disease Prevention and Control since 2011. The CHNS also acknowledges the support of China’s National Institute for Nutrition and Health, the China Center for Disease Control and Prevention, Beijing Municipal Center for Disease Control and Prevention, and the Chinese National Human Genome Center at Shanghai.

This study was based on work supported by a University of Washington Valle Scholarship, a Scholar Award from the Seattle Chapter of the ARCS Foundation, a PEO International Scholar Award and the National Science Foundation Graduate Research Fellowship Program (grant no. DGE-1762114) (all received by L.C.H., the first three received with the assistance of J.K.). Any opinions, findings and conclusions or recommendations expressed in this article are those of the authors and do not necessarily reflect the views of the University of Washington, ARCS Foundation, PEO International or National Science Foundation. We are grateful for the coding help provided by the University of Washington Center for Social Science Computation and Research and methods suggestions offered by the Center for Statistics and the Social Sciences, with a special thanks to J. Herting and S. LaPlante. Any errors are the sole responsibility of the authors.

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  1. These authors contributed equally: Leigh C. Hamlet, Suman Chakrabarti.

Authors and Affiliations

  1. Department of Civil and Environmental Engineering, University of Washington, Seattle, WA, USA

    Leigh C. Hamlet & Jessica Kaminsky

  2. Nutrition, Diets, and Health Unit, International Food Policy Research Institute, Washington DC, USA

    Suman Chakrabarti

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L.C.H. and S.C. conceptualized the study, curated the data, chose the methodology, performed the formal analysis and wrote the original draft. L.C.H. and J.K. acquired funding. All authors reviewed and edited the manuscript.

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Correspondence to Leigh C. Hamlet.

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Supplementary Methods, Results, Tables 1–20 and Figs. 1–11.

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Hamlet, L.C., Chakrabarti, S. & Kaminsky, J. Environmental sanitation and undernutrition among China’s children and adolescents from 1989 to 2011. Nat Water 1, 736–749 (2023). https://doi.org/10.1038/s44221-023-00112-6

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