Water, sanitation, and hygiene and nutritional status of children under-5 years born to young mothers in Ghana: a spatial inequality analysis.

BACKGROUND: Malnutrition among children under five remains a major public health challenge in sub-Saharan Africa, with those born to young mothers being particularly vulnerable. Evidence on the role of water, sanitation, and hygiene (WASH) in this subgroup is limited in Ghana. We estimated the association between WASH and childhood malnutrition, and characterized its spatial and socioeconomic distribution, in young mother-child pairs in Ghana. METHODS: We analyzed 620 child-mother pairs (mothers aged 15-24 years) from the 2022 Ghana Demographic and Health Survey. Outcomes were stunting, wasting, and underweight, defined using WHO growth standards (< -2 SD). Survey-weighted multilevel logistic regression examined WASH-nutrition associations. Spatial patterns were assessed using Global Moran's I, and LISA and Getis-Ord G*. Socioeconomic inequality was measured via concentration indices, the Theil T index, Lorenz curves, and difference/relative indices. Population attributable fractions (PAF) and risks (PAR) were estimated for binary WASH exposures. RESULTS: Stunting prevalence was 18.8% (95% CI 15.5-22.6), wasting 8.7% (6.2-11.9), and underweight 15.6% (12.4-19.4). Volta Region recorded the highest observed weighted prevalence for all three outcomes (stunting 32.0%, wasting 16.8%, underweight 39.4%), but these estimates were based on a small subsample (unweighted n = 20). Global spatial autocorrelation was not statistically significant for any outcome (all p ≥ 0.296). LISA identified Oti as a possible hotspot for underweight (p = 0.039), and Central and Bono as cold spots for stunting (p = 0.047) and wasting (p = 0.018). Improved water access showed the largest protective population-level association (PAF: stunting -36 to -41%; underweight -37%), interpreted as a population-level attributable-burden estimate under a cross-sectional design. Concentration indices were negative for all outcomes, indicating disproportionate burden among poorer and less-educated households, reaching statistical significance for underweight. WASH covariates were not significantly associated with any outcome in fully adjusted models. Multilevel models showed high apparent discrimination (AUC 0.859-0.868). CONCLUSION: Malnutrition among children of young mothers in Ghana is unevenly distributed and concentrated among socioeconomically disadvantaged populations. Equitable WASH services, alongside targeted nutrition programming, may help reduce nutritional inequalities in support of SDG 2 and SDG 6.