Association between Diarrhea, malnutrition, and dehydration with school water, sanitation, and hygiene


eMediNexus    14 December 2022

Diarrhea, malnutrition, and dehydration endanger millions of lives of children globally due to inadequate water, sanitation, and hygiene (WaSH). The present study identified environmental and behavioral risk factors for these health outcomes among school children in Metro Manila, Philippines.


It analyzed data from a multistage cluster sample of school children in grades 5, 6, 7, 9, and 10 (ages ~10–15 years old) to investigate WaSH facilities and hygiene practices. The study looked for self-reported Diarrhea, measured via questionnaire; observed malnutrition (stunting, undernutrition, over-nutrition), measured via anthropometry; dehydration, measured via urine specific gravity/urine test strips.


The study observed-


  • Inclusion of 1558 students from 15 schools in three cities. 
  • Diarrhea in over 28% of students and dehydration in 68%.
  • Over 15% of students were stunted, ~9% were undernourished, and >21% were over-nourished. 
  • Association of diarrhoea with poor handwashing and dehydration with the lack of water in school restrooms. 
  • Association of stunting with not using the school restroom, the lack of water in school restrooms, and the lack of hygiene lessons in school. 
  • Association of undernutrition with the lack of a school restroom cleaning policy. 
  • Decreased risks of diarrhea, stunting, and undernutrition with the increase in the number of school restrooms. 
  • Decreased risks of stunting and overnutrition with an increase in the number of school toilets. 
  • Association between having more than seven handwashing basins with decreased risk of dehydration.


The findings from this study cannot describe causation. It found associations suggesting that school restroom cleaning policies, good water supply, enhanced handwashing, and hygiene education are must to prevent disease. School-based WaSH interventions are recommended to supply water in school WaSH facilities, encourage handwashing, and boost hygiene-related knowledge.


Sangalang SO, Prado NO, Lemence ALG, et al. Diarrhoea, malnutrition, and dehydration associated with school water, sanitation, and hygiene in Metro Manila, Philippines: A cross-sectional study. Science of The Total Environment. 2022;838(2). https://doi.org/10.1016/j.scitotenv.2022.155882.

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