Children with disabilities lack access to nutrition, health and WASH services: A secondary data analysis

Abstract Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross‐sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55–0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02–1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities.


| INTRODUCTION
An estimated 45% of deaths in children younger than 5 years old globally have undernutrition as an underlying or contributory cause.
Millions more are affected by infections and other morbidity, which can result in long-term impacts to children's health and development (Black et al., 2013;Grey et al., 2021;Lelijveld et al., 2016).
Despite progress towards the 2030 Sustainable Development Goals (SDG), some 22% (149.2 million) of children globally are stunted, 6.7% (45.4 million) are wasted and 5.7% (38.9 million) are overweight (United Nations, 2022;Victora et al., 2021).While malnutrition and micronutrient deficiencies have decreased globally, a high burden of these conditions continues in low-and middleincome countries (LMICs), including many in Sub-Saharan Africa (SSA) (Onyango et al., 2019;Quamme & Iversen, 2022).Malnutrition, poor dietary diversity and limited healthcare access are all factors leading to increased incidence of infections, preventable deaths, chronic disease, impaired immune function, disability and impacted economic and educational outcomes (Black et al., 2013;Han et al., 2022;Tam et al., 2020).Infections can cause or worsen malnutrition by factors such as increased nutritional needs, gastrointestinal damage, malabsorption and reduced appetiteperpetuating a vicious infection/malnutrition cycle (Katona & Katona-Apte, 2008).However, despite a high need for nutrition and health services (NaHS) in SSA, access is low (42.56%),particularly for women, children and people with low socioeconomic status, low levels of education, rural residence and those with disabilities (Tessema et al., 2022;World Health Organization, 2011).Specifically, access to Vitamin A supplementation, treatment for malnutrition, vaccination, HIV care and deworming remains low (Black et al., 2013).For example, only 59.4% of children under the age of 2 are reached by vitamin A supplementation coverage in SSA (Berde et al., 2019).Insufficient NaHS access often occurs in tandem with other inaccessible household needs such as nutritious food and clean drinking water (Black et al., 2013;Drammeh et al., 2019).Some 17 million individuals in SSA are food-insecure, have poor water access, sanitation and hygiene (WASH) adding additional challenges to already stressed households and contributing to the high prevalence of malnutrition and micronutrient deficiencies (Drammeh et al., 2019;Masangcay et al., 2021).
Globally, mortality and morbidity related to poor WASH is declining, with the exception of SSA where there is particularly low coverage of access to safe drinking water and sanitation (Fuente et al., 2020;World Health Organization [WHO], & United Nations Children's Fund [UNICEF], 2021).Widespread public health issues, climate change and other factors have further exacerbated existing gaps and barriers in access to health care in SSA, with many services closed or overwhelmed and households facing added financial barriers to access (Tessema et al., 2021).Some people, such as those with disabilities, are at especially high risk of malnutrition and infections, which can exacerbate existing disabilities or cause disabilities (Groce et al., 2014;Rotenberg et al., 2024).
Globally, over one billion people are disabled, of which 150 million are children-with 80% of these individuals living within LMICs (Hume-Nixon & Kuper, 2018;United Nations Children's Fund, 2021;World Health Organization, 2011).Children with disabilities are nearly three times more likely to be underweight and twice as likely to be stunted and wasted than children without disabilities (Hume-Nixon & Kuper, 2018;Rotenberg et al., 2024).Despite this, children with disabilities are often missing from malnutrition guidelines, protocols and government policies or initiatives (Engl et al., 2022;United Nations Children's Fund, 2021).The World Health Organization defines disability as, 'The interaction between individuals with a health condition … and personal and environmental factors', which indicates a person's experience of their disability is greatly impacted by the accessibility of their environment.Despite often having higher needs for services, those with disabilities frequently experience barriers, discrimination and stigma when accessing NaHS (Adugna et al., 2020;Groce et al., 2013;Hume-Nixon & Kuper, 2018;World Health Organization, 2011).Some examples of barriers can include inaccessible health facilities or transportation, medical professionals or healthcare programmes not structured or trained to provide services for children with disabilities or stigma against disabilities resulting in children being unwelcome or deemed a lower priority for NaHS (Adugna et al., 2020;Groce et al., 2014).Difficulties accessing essential NaHS can further stress already insecure households with children with disabilities.Children with disabilities are at high risk of abandonment and are disproportionately present in institution-based care (DeLacey et al., 2020(DeLacey et al., , 2021)).Uganda is a key example of a country in SSA where malnutrition, infections, disability and inadequate access to NaHS remain influential factors in morbidity and mortality among children (Global Nutrition Report, 2021;Mawa, 2018).Approximately 7.5% of 5-to 17-year-olds and 3.5% of 2-to 4-year-olds in Uganda have a disability, although this figure may be underestimated (United Nations Children's Fund [UNICEF], 2019).
Uganda has the highest mortality rate from diarrhoeal infections in children younger than 5 years old in East Africa (22%) (Omona et al., 2020).The existing small body of evidence suggests people with disabilities in Uganda face multiple barriers to accessing NaHS and WASH services, however, there is limited information on access to NaHS, household WASH and dietary adequacy for children with disabilities (Adugna et al., 2020;Tessema et al., 2021Tessema et al., , 2022)).

Key messages
• There is low access to essential nutrition and health services for households in Uganda: access barriers need to be examined and minimized.
• Children with disabilities have particularly poor access to key nutrition and health services.Clean water, sanitation and good hygiene for children with disabilities are associated with improved access to nutrition and health services.

| Aim and objectives
The aim of this study is to inform improvements in future nutrition, health and WASH delivery for households in Uganda, with a particular focus on children with disabilities.
We will achieve this through three related objectives: 1. Describe demographics and general access to NaHS, household WASH status and dietary adequacy among households in the study population.We followed the STROBE reporting guidelines and the PECO framework, which outlines the population, exposure, comparator group and outcomes of interest (Table A1).(Mintzker et al., 2022;von Elm et al., 2008).

| Setting
The survey took place in three districts in central Uganda; Mukono, Luwero and Wakiso, where Holt International operates NaHS (Supporting Information: S2).(Uganda Bureau of Statistics, 2020).
1. Wakiso District has a total population of 2,915,200-60% of these are younger than 20 years old and 1,534,200 (52.6%) are females.
2. Mukono District has a total population of 701,400 people and 60% of these are younger than 20 years old and 361,809 (51.6%) are females.
3. Luwero District has a total population of 523,600 people and 60% of these are younger than 20 years old and 262,700 (50.2%) are females.
Holt provides NaHS to rural communities who the Ugandan government previously identified as lacking access to health services.
NaHS include medical checkups and treatment of illnesses for adults and children, immunization, deworming, supplementation, perinatal nutrition and breastfeeding support.

| Participants
Eligibility criteria for participation in the household survey included all households within the sample districts with one or more children younger than 18 years old.An adult from each of the participating households responded to the survey on behalf of the household.The survey was conducted by 15 professional surveyors in Luwero, five in Mukono and five in Wakiso districts, who were supervised by five supervisors, and three team leaders.

| Study size and sampling strategy
The household survey collected data from households participating in Holt's programmes (i.e., family strengthening programmes or sponsorship), as well as households in the districts not participating in Holt's programmes.The survey team contacted local community leaders for village registers of residents.These registers were used to determine numbers of residents for sampling.The sampling strategy utilised for recruiting non-Holt supported households from across the three districts was systematic and unweighted by sampling every second household.Households participating in Holt programmes were purposely sampled from the same communities, with all households eligible for participation.Surveyors were trained in minimizing responder bias, measurement error, ethical practices in surveying, voluntary and informed participant consent, data protection, survey practices to respect cultural norms, practices and participant comfort.At the survey level, systematic sampling was used and community leaders were engaged to encourage all to take part, thereby minimizing response bias.If a family was absent during the survey, the surveyor would return the next day.Respondents self-reported on behalf of their households.Mid-upper arm circumference (MUAC) measurements of children were taken by a trained surveyor using coloured MUAC tapes for all children ages 6 months to 5 years old who were present at the time of the survey.

| Survey questionnaire
The survey questionnaire was designed by Holt International as part of routine programming and data collection in Uganda (Supporting Information: S2).The survey focused on household access to NaHS and included questions regarding health access and needs, WASH, nutrition and dietary adequacy, as well as demographic information.
This survey was conducted to inform and improve Holt's programming and services and provide information for scale-up of NaHS in the area.Survey questions' responses included binary, categorical, free text or numerical variables.Disability status was self-reported by respondents on behalf of their households.Households were asked if they had a child with a disability with a response of 'yes' or 'no'.If yes, then additional questions on self-reported disability type, impact to daily functioning, difficulties eating and others were asked of the respondent (Table A4).Other questions in the survey included how many meals a day a child received and their consumption of food from five food groups as reported by the respondent (Table A4).

| Data analysis
A deidentified, fully anonymized data set was used for analysis.A conceptual framework to understand potential confounders was created before analysis, with WASH and dietary adequacy selected as potential effect modifiers to be explored as proxy markers of poverty.A statistical analysis plan was created before analysis and guided the analysis process to reduce potential bias.STATA software (version SE 17) was used for all statistical analysis (StataCorp, 2017).Duplicates and outliers were explored and removed.Missingness of data was explored with a view to conducting a complete case analysis if missingness was low (<5%).The main exposure variable was households with children with disabilities, and the main outcome variable was self-reported household access to NaHS.For the outcome, a binary variable was used based on the question, 'Do you currently have access to all health services that you need?', to which participants answered either 'yes' or 'no'.A directed acyclic graph (DAG) was created to explore the association between the exposure (children with disabilities in the household) and outcome (access to NaHS) alongside potentially confounding factors to inform regression models (Figure A1).
A WASH adequacy score was generated based on the questionnaire to synthesize household WASH adequacy.The initial questionnaire asked nine questions relating to WASH adequacy (Supporting Information: S2).The survey question, 'In the last one month, has there been a time when you did not have sufficient water for drinking?',with a response of 'yes' or 'no', was taken as an overall indicator of WASH adequacy for use as a binary variable in analytical statistics.Additionally, a WASH adequacy score was created based on summing responses from some of the WASH-related questions, with a higher score indicating greater adequacy of WASH services.
The WASH adequacy score also took into account the safety of the water source, with bottled water and piped water receiving higher scores and open wells receiving the lowest score.To analyse dietary intake, binary 'yes' or 'no' variables were created if a child consumed three meals a day or if they consumed food from the five food groups measured over the previous 7 days.From these two variables, the dietary adequacy variable was generated based on if a 'yes' was reported for both of those variables (Table A5).
The survey included data on individual child MUAC measurements from participating households (Supporting Information: S2).
These anthropometric measurements were analysed for children 6 months to 5 years old based on WHO guidance, with severe malnutrition classified as less than 11.5 cm, moderate malnutrition less than 12.5 cm, and within normal range being greater than or equal to 12.5 cm (World Health Organization, 2019).Data outliers were removed to correct for measurement error, based on a plausible range of 8.5-20.0cm for children ages 6 months to 5 years.Children with disabilities were included in this measurement.
Descriptive statistics were used to summarise demographic characteristics of included children and households, with counts and proportions reported for each categorical variable.Count variables for household size and number of children per household were summarised as median, interquartile range and total range.Continuous variables were described using mean and standard deviation.Descriptive statistics were reported by household status; all households, those with children with disabilities and those without children with disabilities.χ 2 test of association (or Fisher's exact test where appropriate) and t tests were used to compare characteristics of households with and without children with disabilities.
Logistic regression was used to explore the association between a binary explanatory indicator of child disability within the household and a binary outcome indicator of household access to NaHS.Adjusted analysis included all potentially confounding factors identified from the DAG (Figure A1).Interactions were fitted between the main exposure and both WASH and dietary adequacy which were used as proxy indicators of poverty, to establish if the association between exposure and outcome differed by access to WASH services and nutrition.
Interaction terms were tested using a likelihood ratio test.

| Ethical statement
Ethical review and approval for this study was received from the London School of Hygiene and Tropical Medicine (Reference: 27255).
Research was conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable standards.

| RESULTS
A total of 12,260 non-Holt-supported households were indicated from the village registers, with a sample of 6130 participants for the survey.A total of 853 Holt-supported households were recruited from purposive sampling and data was collected from 7013 households in total.The 70 households in the sample with no children were excluded, with a further 19 households removed due to missing data on the number of children in the household (Figure 1).Household identification numbers were explored for duplicates and none were found.This resulted in a sample of 6924 households reporting at least one child in the household included in the analysis (Figure 1).
In total, 305 (4.4%) of households reported at least one child with a disability.Loss of a child younger than 5 years old was reported by the last 5 years, with households with children with disabilities reporting a higher proportion of miscarriage (15.4% vs. 8.6% p < 0.001) (Table A4).
The distribution of number of people and number of children in the household was similar across districts.The median number of people in each household was five (IQR 4-6), with a median of three children in each household (IQR 2-4) (Table 1).Missingness was negligible among demographic variables (<1.5%), most having no missing data.
Information on access to NaHS indicated insufficient access for households with and without children with disabilities (Table 1).
Households with children with disabilities reported lower access to necessary health services than households without children with disabilities (49.5% vs. 58.9%p = 0.001).Only 644 (9.3%) of households had ever attended a Holt NaHS.Most households (6065 [87.4%]) reported visiting a health centre when they are sick.
Households with children with disabilities had a higher prevalence of illness in the last two weeks, including diarrhea, skin infections, cough or fever, than those without children with disabilities (76.7% vs. 67.3%,p = 0.001) (Table A2).
Of the 6862 households that provided responses on child dietary adequacy for children older than 2 years old, 4488 (64%) of households reported children having three meals a day, with a slightly higher proportion among households without children with disabilities (65.7% vs. 60.6%p = 0.073) (Table 2, Table A2 and Table A3).Overall, 1196 households (17.4%) reported children meeting the criteria for dietary adequacy.Of the households with children with disabilities, only 44 (14.4%) reported dietary adequacy.MUAC was measured for 8357 children, of which 221 (2.6%) were malnourished (MUAC less than 12.5 cm).Households with children with disabilities were more malnourished than those without (28/442 [6.3%] vs. 190/ 7785 [2.4%] p < 0.001) (Table 2 and Table A2).
A total of 1531 (22.1%) households reported lacking sufficient drinking water in the last month.WASH adequacy score was approximately normally distributed (mean:11.8,SD:2.9), and the median score in all districts was 12 out of a possible total of 20 (IQR F I G U R E 1 Data flow chart indicating the number of households included in the analysis. T A B L E 1 Demographic characteristics of households by households with and withoutded households were most commoded households were most commo children with disabilities.| 7 of 20 10-14).Households with and without children with disabilities had similar WASH adequacy scores (Table 2, Table 4 and Table A5).
The unadjusted odds of reporting access to all NaHS needed was 32% lower (OR = 0.68; 95% CIs 0.54-0.86;p = 0.001) for households with children with disabilities compared to households without children with disabilities, indicating very strong evidence of an association (Table 3).The fully adjusted odds ratio (OR = 0.70; 95% CIs 0.55-0.89;p = 0.003) indicates households including children with disabilities had 30% lower odds of having access to NaHS than households with no children with disabilities, with very strong evidence of an association persisting after adjusting for sociodemographic characteristics, WASH and dietary adequacy.
For households with a WASH score of 0, that is those with the lowest WASH adequacy, having a child with a disability was associated with 81% lower odds (OR = 0.19; 95% CIs: 0.06-0.57;p = 0.003) of having access to NaHS compared to households that did not have any children with disabilities (Table 4).Odds of access to NaHS for households with children with disabilities increased by 12% for every 1 unit increase in WASH score, with strong evidence of an interaction between having a child with disabilities and WASH score on the outcome of access to NaHS (interaction odds ratio; 1.12, 95% CIs: 1.02-1.22,p = 0.012).There was no evidence of interaction between households with children with disabilities and insufficient drinking water (p = 0.360), consuming food from all food groups in last week (p = 0.957) or children having three or more meals a day (p = 0.785) in their associations with access to NaHS (Table 4).

| DISCUSSION
This study describes access to nutrition and health services among households with and without children with disabilities in Uganda and explores interactions with WASH and dietary adequacy.
We  (Adugna et al., 2020;Harrison et al., 2020).Our research found that access to NaHS was significantly worse for households with children with disabilities, with households having 30% lower odds of access to NaHS than households without children with disabilities even after adjusting for sociodemographic characteristics, WASH and dietary adequacy, which were used as markers of poverty.However, this could be an underestimate of the true prevalence due to factors such as stigma reducing reporting or lack of access to healthcare reducing diagnosis (Adugna et al., 2020;Engl et al., 2022;World Health Organization, 2011).This corroborates existing research that access to NaHS in SSA, and Uganda specifically, is worse for children with disabilities (Adugna et al., 2020;Harrison et al., 2020;Tessema et al., 2022).
This is imapctful because we found households with children with disabilities experiencing a higher prevalence of illnesses, including diarrhea and skin infections.Article 25 of the United Nations Convention on the Rights of Persons with Disabilities sets out the rights of people with disabilities to receive high standards of equitable health care, free from discrimination and stigma but these standards can often be challenging to obtain when individuals face obstacles such as physical access or financial limitations (Adugna et al., 2020;United Nations, 2006).For example, in Ghana, households with children with cerebral palsy report favouring athome treatment only due to the high cost of medical treatment, caregiver burden and stigma associated with disability (Fonzi et al., 2021).Together, these findings highlight the magnitude of both the inequality and the need to improve accessibility of NaHS for children with disabilities.

| Water access, sanitation and hygiene
Deworming and vaccinations were reported as the most important NaHS to respondents, yet these services were also reported as least

| Strengths and limitations
The research utilized a large data set from a household survey with very little missing data.This research provides recent information on access to NaHS, WASH and nutrition in Uganda.The last published DHS is from 2016 and does not reflect the impact of the COVID-19 pandemic (Uganda Bureau of Statistics-UBOS and ICF, 2018).
However, the findings presented in this project must be considered in line with multiple limitations when interpreting results.
First, only the three districts of Wakiso, Luwero and Mukono were surveyed, thus the findings may not be representative of Uganda as a whole-it is possible there are additional notable regional differences in health, nutrition and access to services (Uganda Bureau T A B L E 4 Stratum-specific odds ratios and test for interactions between households with a child with a disability and household access to nutrition and health services by drinking water sufficiently, WASH adequacy score, dietary intake and child having three meals a day. of Statistics-UBOS and ICF, 2018).Additionally, the sample was unweighted, and information on probability of selection was not available.Therefore, those purposively sampled as Holt-supported households are overrepresented and the non-Holt supported households are underrepresented in the findings and information on response rate was not available.Systematic sampling was used to minimize selection bias as was training and supervision of surveyors, although all information was self-reported by respondents on behalf of the household.The potential for responder bias should be taken into account when interpreting the findings.
This survey was conducted at the household level, therefore it was not possible to link any other information such as age or gender to the child with a disability, nor how many children in the household had a disability, but only to differentiate between households by whether any child had a disability.Disability status was self-reported, future surveys should use a more standardized way of capturing functional difficulties in the communities, such as using the Washington Group Questionnaire (Washington Group on Disability Statistics, 2001).The prevalence within these communities of children with disabilities is likely higher than reported, as families may only report disability status if formally diagnosed.
There was the potential for measurement error during recording of survey responses, where some responses may have been written incorrectly, resulting in some implausible values.Measurement error could also have occurred when measuring children's MUAC, especially as there is limited guidance on applicability of MUAC use for children with disabilities (Hayes et al., 2023).Other anthropometric measurements were not taken limiting the full picture of the malnutrition situation in the region-wasting may be low but potentially other indicators such as stunting, may indicate a higher prevalence of malnutrition.
While efforts were made to adjust for potentially confounding factors, as much of the data was at the household level and not linkable to individuals, it was not possible to adjust for important confounding factors or such as age and gender, thus residual confounding should be taken into consideration when reviewing the outcomes.In the future, surveys should aim to use validated measures of dietary adequacy or WASH scores or explore other indicators of poverty, like household income, which was not measured in this survey.Due to the survey design, individual child MUAC measurements and disability status were not linked, and future research should investigate the relationship between MUAC measurements, disability and malnutrition (Hayes et al., 2023).Due to the nature of crosssectional studies, it was not possible to establish temporality with regard to exposure and outcome.It is likely that some of the disabilities reported, such as visual impairments, could have resulted from lack of access to NaHS or vitamin A supplementation.Therefore, the findings could present reverse causality from a bidirectional relationship, with poor access to NaHS leading to increased child disability as malnutrition and illness are major causes of disability.Those with poor WASH and dietary adequacy are therefore also more likely to develop a disability.This presents an important limitation of the interpretation.However, this does not impact the key message of the findings relating to the necessary improvement of access to NaHS both for children with disabilities and to prevent future illness and disability in general.

| Recommendations
Future research should explore the needs of households with children with disabilities to improve access to essential services.

2.
Examine access to NaHS for households with children with disabilities and without disabilities.3.Explore WASH and dietary adequacy for households with children with disabilities and without disabilities.
Study designThis is a secondary analysis of cross-sectional survey data originally collected in 2021 by Holt International in Uganda.Holt International is an international child welfare nonprofit which provides support and services to orphaned and vulnerable children and their families in 15 countries (Holt International, 2022).Holt International has worked in Uganda since 2006 and provides NaHS services to children and families in three districts.Ethical approval was received from the London School of Hygiene and Tropical Medicine-(Reference: 27255) for this study.
Understanding the barriers and facilitators to full inclusion and ensuring all people's needs are met must be prioritized.Improving WASH facilities should be a key focus of NaHS for households with individuals with disabilities.Policy makers, government officials, local civil society organizations and NGOs should include those with disabilities in their planning and decisions.This research also identified that key practice and policy recommendations should ensure that deworming and vaccination services are included in NaHS, especially those targeting rural and hard-to-reach populations.5 | CONCLUSIONSubstantial gaps remain in access to NaHS for households in Uganda, especially for households with children with disabilities.Access to essential services such as deworming and vaccinations falls short of family needs.There is also a need for increased WASH and nutrition services.Few children are receiving an adequately diverse diet, putting them at risk of malnutrition and micronutrient deficiencies.Access to NaHS is significantly lower for households with children with disabilities compared to those without, even after adjusting for sociodemographic factors, WASH and dietary adequacy.Households with children with disabilities and low WASH adequacy also have dramatically lower access to NaHS than those with high WASH adequacy.This highlights the challenges of poverty and rural residence and the need to improve access particularly for those with the fewest resources.Gaps in these essential services exacerbate inequalities and have implications for nutrition and health outcomes of children, families and communities.To better address the need for access to essential NaHS for families in Uganda, it remains vital that these services are inclusive, accessible and comprehensive.T A B L E A2 Nutrition, food access micronutrient supplementation, child illness and nutritional deficiency symptoms by household status.

F
I G U R E A1 Directed acyclic graph exploring the relationship between child disability and access to nutrition and health services with other factors green circles indicate an ancestor of the exposure on the causal pathway.White circles indicate adjusted variables.Purple arrows indicate a causal pathway.Pink circles indicate an ancestor of both the exposure and outcome, thus on the causal pathway.
found that households with children have insufficient access to (Tessema et al., 2022;cy.Of the households in our study, 57.9% reported having access to all of the NaHS they needed.This suggests above-average access for SSA (42.6%) and for women in Uganda (40%) based on the latest Demographic and Health Survey (DHS)(Tessema et al., 2022; Uganda Bureau of Statistics-UBOS   and ICF, 2018).As statistics on access to NaHS are difficult to obtain Crude and adjusted analysis of characteristics associated with access to nutrition and health services.
accessible.According to the most recentDemographic and Health   Survey (2016)in Uganda, 8.8% of children were infected with soiltransmitted helminths (Uganda Bureau of Statistics-UBOS and ICF, 2018).Deworming pre-school children is associated withT A B L E 3a Adjusted for district, household size, child disability in the household, child illness in the last 2 weeks and food assistance in the last year.bAdditionallyadjustedfor WASH score and dietary adequacy, based on three meals a day and consumption of five food groups in the last 7 days.anadequatequantity of food, while nearly three quarters do not have access to an adequately diverse diet, with implications for undernutrition and particularly micronutrient deficiencies.After adjusting for sociodemographic factors, households whose children had dietary adequacy in the last week had two times the odds of access to NaHS than those without.Of the households with children with disabilities, 39.4% reported children not having three meals a day and 85.6% having an inadequate diet which was similar for households in these communities without children with disabilities.Few children younger than 5 years old (221 Medical support for children with disabilities and disability prevalence.Water access, sanitation and hygiene facilities by household status. a Mid-upper-arm-circumference (MUAC) less than 12.5 cm.(WorldHealthOrganization, 2019).T A B L E A3 Frequency of food group consumption in the last 7 days by children older than 2 years of age.|19 of 20