Review of 'Associations between the household environment and stunted child growth in rural India: a cross-sectional analysis'

General assessment:

This article addresses the very important and chronic issue of child stuntedness across the world with particular focus on developing countries and low-income households. Zero hunger, good health and well-being are the second and third targets under the Sustainable Development Goals (UNDP), and reducing Child stuntedness is an important step towards achieving these goals and is also a key indicator in achieving Global Nutritional Targets for 2025 under WHO. There exists a good number of recent review papers and investigative studies on nutritional and associated environmental influences on child stunting across various South East Asian and African countries. Some examples include “Child stunting is associated with child, maternal and environmental factors in Vietnam” by Beal et al. (2019); “Risk factors of stunting among children living in an urban slum of Bangladesh: findings of a prospective cohort study” by Islam et al. (2018), Understanding correlates of child stunting in Ethiopia using generalized linear mixed models by Takele et al. (2019).  This study follows similar trends in that it focuses on child growth and associated factors in the rural region of Rajasthan, India. Majority of these studies have looked into both malnutrition and some environmental factors, or specific ones such as drought, this paper differs from other studies in its focus on environmental factors (drinking water quality according to source, sanitation facilities, cooking fuel type and agricultural land ownership) rather than nutritional shortcomings in influencing child growth which gives it novelty and strong justification.

The introductory paragraph states that  ”India is the priority target to set the pace of progress towards a better-nourished world” but does not explain why India specifically; is it because of India’s significant population, economic leadership or geographical area? How does the lasting impact of malnutrition transcend generations? (second paragraph under ‘Introduction’). In the list of household factors that positively impact nutrition, under no 1, what is Scheduled Castes or Tribes?. In no 2, does women’s education influencing nutrition positively include all women or mothers and household managers? Under aim of study, I feel more justification is needed for why four specific household environmental factors were chosen and I am curious to know how authors came to the decision of focusing on these four environmental factors. Are there other existing factors such as population size, seasonality, geographic location, communicable diseases such as malaria and dengue? .

Under Methods, in sec 3.2, "each household respondent was invited to provide informed consent...." does not specify if all members were interviewed or not, a clearer description of the process would be helpful. In sec 3.2.1 the method of respondents selecting one sub-category under the four main categories is also not clear. How was data collected consistently if focus was on different sub categories for interviews in individual households? Under statistical analyses section the part on household characteristics as independent variables, and stunting as dependent variables could be mentioned prior to, or along with the previous section on age as a confounding variable to provide better perspective to the reader. Under sec 3.1.1 “of the 1194 cases, 72.3% of cases belonged to families…” are these cases of stunting? Overall, the methods section is weak in comprehensibility.  

The discussion section provided a comprehensive picture of the above existing environmental conditions in rural India but better comparisons could have been done using more recent studies (2015 to 2020) conducted in countries with similar socio-economic backgrounds such as Vietnam, Myanmar and so on, not just Bangladesh. This study does refer to correlation between parental formal education and improved child health under 5 in Indonesia and Bangladesh in 2008 and also brings up randomized controlled trials conducted in Bangladesh on handwashing, sanitation and water quality showing no significant impact on child growth versus when only sanitation was addressed in 2018.

Limitations were well articulated and displayed adequate self-reflection. The conclusion highlighted the importance of diversifying the causes of child stuntedness to include environmental factors. Improved sanitaion had the highest odds on reduction of child stuntedness; followed by agricultural land ownership and better drinking water supply, while use of biofuel type had little infleunce. I found the result for agricultural land ownership and child stuntedness eye opening in particular. This  study has broadened my understanding of the environment and health nexus and will contribute towards inclusive policy making and better environmental practices (sanitation in particular based on the results) in low-income households across developing countries.  

Presentation style:

The introduction and methods sections are weaker than the results and discussion and requires further clarification on certain points and statements made as mentioned under general assessment above. The results section is well presented with clear tables followed by brief interpretations. I found the methods section particularly confusing in that it did not describe and provide a clear picture of the way the surveys and interviews were conducted in the field. There is a small language edit in the second sentence of the introductory paragraph ‘remains unmet’ vs ‘remains to be unmet’.

Given that a plethora of recent literature exists on the issue of child stuntedness and many studies have already been conducted, including extensive review papers such as “Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan” (Kim et al. 2016) the discussion could be further strengthened using these studies. This will make the literature review more rigorous and current (unless the authors are looking at the timeline of this study , data collection and matching it with studies within that time line).The authors could also include some pictures of children and environmental conditions of households  in the area  where the study was conducted for better visualization of existing conditions.

Conclusion: Correlates child stuntedness and environmental factors thoroughly, needs more recent literature review and clarification under methods