Water, sanitation, and hygiene and their association with child undernutrition: a hierarchical analysis of the 2020 Somaliland demographic health survey

Background: Child undernutrition, manifested as stunting and wasting, remains a major public health concern globally, particularly in Somaliland. Inadequate Water, Sanitation, and Hygiene (WASH) are known contributors, their specific associations in Somaliland require investigation. This study examined the hierarchical relationships between WASH indicators and child undernutrition. Methods: We analyzed data from the 2020 Somaliland Demographic and Health Survey, including a weighted sample of 3,240 children aged 0-59 months. Stunting and wasting were defined using WHO 2006 Child Growth Standards. Household WASH indicators (latrine facility, drinking water source and water collection time) served as exposures. Multilevel logistic regression was used to assess associations, reporting Adjusted Odds Ratios (AORs) with 95% Confidence Intervals. Results: The prevalence of stunting was 23.4% and wasting 21.3%. Improved sanitation was associated with lower odds of stunting (AOR = 0.69; 95% CI: 0.56-0.86), while unimproved sanitation increased the likelihood of wasting (AOR = 1.30; 95% CI: 1.02-1.68). Children in households requiring less than 30 min to collect water had higher odds of stunting compared with those with water on premises (AOR = 1.39; 95% CI: 1.11-1.75). Female children were more likely to be wasted, and significant regional disparities in stunting were observed. Conclusion: Child undernutrition in Somaliland remains high and is strongly influenced by sanitation access, water-collection burden, and regional inequalities. Strengthening household sanitation and improving water accessibility are essential to reduce child undernutrition.