Exploring Beyond the Cyclical Dynamics of Water, Sanitation, and Hygiene With Coexisting Forms of Malnutrition Among Children Under 5 in Pakistan

Coexisting forms of malnutrition (CFM) represent a critical global health priority, particularly among children under 5, owing to their severe consequences and elevated mortality risk compared to standalone forms of malnutrition. This study was aimed at assessing the relationship between household water, sanitation, and hygiene (WASH) conditions and CFM among children under 5 years in Pakistan.

This cross-sectional study utilized data from the last two waves of the Pakistan Demographic and Health Survey (PDHS) conducted in 2012-2013 and 2017-2018. From these datasets, data for a total of 6874 children aged between 0 and 59 months were included for analysis. Children who were non-de jure residents, deceased at the time of survey, or had missing or flagged anthropometric data (outliers) were excluded. The data was analyzed using bivariate and multivariate logistic regression models. The four CFM outcomes examined were coexistence of underweight with wasting (CUW), coexistence of underweight with stunting (CUS), coexistence of underweight, wasting, and stunting (CUWS), and coexistence of stunting with overweight/obesity (CSO), each defined using WHO anthropometric cut-off values (z-score ≤ -2 SD for undernutrition indices and ≥ +2 SD for overweight/obesity).

Key findings revealed three distinct WASH-nutrition patterns. First, improved drinking water access was strongly associated with concurrent under- and overnutrition. CUW and CSO had lower odds by 85% and 59%, respectively. Second, infection prevention played a significant role. Children without diarrhea and fever in the last 14 days were associated with lower odds of CSO by 38%-45%, highlighting the protective role of infection prevention. Third, socioeconomic and maternal factors showed divergent effects. Children of highly educated mothers had 72% lower odds of CUS compared to uneducated mothers. Both maternal and paternal employment had a protective role in various forms of CFM. Additionally, children from the richest households demonstrated decreased odds of CUW (OR: 0.13, CI: 0.05-0.34) but increased odds of CSO (OR: 2.43, CI: 1.46-4.03), signifying a nutritional transition associated with affluence.

This study is among the first to demonstrate that distinct WASH indicators differentially shape coexisting malnutrition patterns in Pakistani children under 5. Improved drinking water access mitigates concurrent undernutrition. Higher household wealth paradoxically elevates the risk of stunting-overweight coexistence, underscoring the dual burden of malnutrition in transitioning economies. These findings call for integrated WASH-nutrition policies with equity-sensitive approaches to accelerate Pakistan's progress toward SDGs 2 and 6.