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

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. China’s history of large-scale water, sanitation and clean energy investments offers promising insights into the development of new interventions to reduce linear growth faltering among children and adolescents.