WASH’ NutritioN - Action Against Hunger · 2019-12-18 · WAsh’nutrition A practical guidebook list of figures Figure 1: DIFFERENT TYPES OF UNDERNUTRITION 17 Figure 2: CONCEPTUAL

1

WASH’NutritioNA prActicAl guidebook on increAsing nutritionAl impAct through integrAtion of WAsh And nutrition progrAmmesFor practitioners in humanitarian and development conteXts

2WAsh’nutritionA practical guidebook

3WAsh’nutrition

A practical guidebook

WAsh’nutrition

A prActicAl guidebook on increAsing nutritionAl impActthrough integrAtion of WAsh And nutrition progrAmmes

For practitioners in humanitarian and development conteXts

5WAsh’nutrition


tAble of contentsstAtement on copYright 6AcknoWlegements 7hoW to use this guidebook 8foreWord 9lists of figures - tAbles - boXes - mAps 10 list of AcronYms 12

1 – the bAsics of undernutrition And WAsh 141. Definingundernutrition 172. Themaincausesofundernutrition 193. The“1,000days”windowofopportunity 204. Undernutritionconsequences 205. Addressingundernutrition 226. GlobaltrendsinundernutritionandWASH 27

2 – linking nutritionAl outcomes With the WAsh environment 301. NutritionalstatusandtheWASHenvironmentrelationship 332. Keypathwaystoundernutrition 343. ContributingWASH-relateddiseases 374.WASHinterventionseffectsonhealth 38

3 – WAsh’nutrition strAtegY And progrAmming 421. AligningWASHandNutritionprogramming 452. Integration 463. Focusonthemotherandchilddyad 544. Emphasisonbehaviourchange 575. Coordinationofstakeholders 596. EnsuringaWASHminimumpackage 62

4 – integrAting Activities At different levels And conteXts 701. Attheindividualandhouseholdlevel 732. Atcommunitylevel 843. Atinstitutionallevel(healthcentres&schools) 954. Atnationallevel 1045. Integratinginterventionsinemergencies 107

5 – monitoring And evAluAtion of integrAted interventions 1161.Monitoringintegratedactivities 1192. Impactevaluationofintegratedinterventions 122

6 – moving toWArds uptAke 1241. Operationalresearch 1272. Capacity-buildingandtools 1283. Communicationanddissemination 1304. Targetedadvocacy 132

progrAmmAtic resources 138


stAtement on copYright

COPYRIGHT©ACFInternational-January2017Reproductionispermittedprovidingthesourceiscredited,unlessotherwisespecified.Ifreproductionoruseoftextualandmultimediadata(sound,images,software,etc.)aresubmittedforpriorauthorization,suchauthorizationwillcancelthegeneralauthorizationdescribedaboveandwillclearlyindicateanyrestrictionsonuse.

This document covers the humanitarian activities implemented with the financial support of the European Union. TheviewsexpressedhereinshouldnotinanywaybetakentoreflecttheofficialopinionoftheEuropeanUnion.TheEuropeanCommissioncannotbeheldresponsibleforanyusethatmaybemadeoftheinformationcontainedinthisdocument

NON-ResPONsIbIlITY ClauseThepresentdocumentaimstoprovidepublicaccesstoinformationconcerningtheactionsandpoliciesofACF.Theobjectiveistodisseminateinformationthatisaccurateandup-to-dateonthedayitwasinitiated.Wewillmakeeveryefforttocorrectanyerrorsthatarebroughttoourattention.Thisinformation:

• issolelyintendedtoprovidegeneralinformationanddoesnotfocusontheparticularsituationofanyphysicalperson,orpersonholdinganyspecificmoralopinion;

• isnotnecessarilycomplete,exhaustive,exactorup-to-date;

•sometimesreferstoexternaldocumentsorsitesoverwhichtheAuthorshavenocontrolandforwhichtheydeclineallresponsibility;

•doesnotconstitutelegaladvice.Thepresentnon-responsibilityclauseisnotaimedatlimitingACF’sresponsibilitycontrarytotherequirementsofapplicablenationallegislation,oratdenyingresponsibilityincaseswherethesamelegislationmakesitimpossible.

Author: JovanaDodos([email protected]),PublicHealthconsultant-ExpertiseandAdvocacyDepartment,WASHsector,ACF-FranceDesign:CélineBeuvinPhoto on cover PAge: ©B.Stevens/i-ImagesforActionAgainstHunger

©ActionContrelaFaim2017,14/16BoulevarddeDouaumont-CS80060-75854ParisCedex17-France

Asoftcopyoftheguidebookmaybedownloadedat:www.actioncontrelafaim.org

7WAsh’nutrition


AcknoWledgements

ThisguidebookhasbeenpreparedbyActionContrelaFaim-ACFandfinanciallysupportedbytheEuropeanCommission’sDirectorate-General for EuropeanCivil Protection andHumanitarianOperations (ECHO).An international group ofmorethan 20 experts in the fields ofWASH,Nutrition andHealth, togetherwith numerous field practitioners, contributed toitsdevelopmentbyparticipating in thepeer reviewprocess,providing technicalexpertise, insightful reflections, ideasandmaterials.Theauthorisdeeplygratefulfortheirsupport.Sincerest thanks are extended toACF-FranceDirection of Expertise andAdvocacy (Dr S. Breysse,Dr J. Lapègue - Projectcoordinator)andACF-US(ZviaShwirtz,EllynYakowenkoandGezahegnMetosso)forholdingtheproject.ThankstotheACFmissionsinSenegalandAfghanistanforhostingfieldvisits,providinginputsandsharingtheirinvaluablefieldexperienceinWASHandNutritionintegration.ThanksgotoMsMarielleLabadens,HeadoftheWater,SanitationandHygieneProgrammeinSenegal,andMrFedericoSoranzo,WASHHeadofDepartmentinAfghanistan,fortheirimmensesupportinorganizingthefact-findingmissions.SpecialthankstoUNICEFWCARO(FrançoisBellet),ECHO-Dakar(DamienBlanc)andUNICEFNew-York(DianeHollandandLizetteBurgers).

THe PeeR RevIew GROuPMrBenHobbs, International Campaign Manager, Generation NutritionMsClaireGaillardou,WASH - DRM Advisor for West and Central Africa, Action Against Hunger MrDamienBlanc,Water, Sanitation and Hygiene Expert, ECHOMsDianeHolland,Nutrition Advisor, UNICEFMrFrançoisBellet,WASH Specialist, UNICEF Regional Office for West and Central Africa, Regional WASH Group CoordinatorMrFranckFlachenberg,Environmental Health Technical Advisor, Concern WorldwideDrJeanLapègue,Senior WASH-DRM Advisor, Action Against Hunger MsMarie-SophieWhitney,Global Nutrition Expert, ECHOMsMargaretMontgomery,WASH Technical Officer, WHOMrNicolasVilleminot,Senior WASH Technical Advisor, Action Against Hunger MrPabloAlcaldeCastro,Senior WASH Advisor, Action Against Hunger MsRachelLozano,Nutrition survey and prevention advisor, Action Against Hunger MsRenukaBery,Senior Programme Manager, WASHplus project, FHI 360MrRonClemmer,Strategy & Business Development Manager, WASH, FHI360MsRuthNashipayiSituma,Nutrition Specialist, UNICEF

THe CONTRIbuTORsMrArnoCoerver,Global WASH Advisor, Malterser International MsJonaToetzke,GIZ/ACF WASH and Nutrition consultantMrJohannesRück,Project Coordinator WASH & Nutrition, German Toilet OrganizationMrJohnBrogan,Water Sanitation & Hygiene Advisor, Terre des hommesMsJordanTeague,Associate Director for WASH Integration, WASH AdvocatesMsKateGolden,Senior Nutrition Advisor, Concern Worldwide MsLailaKhalid,Grants Coordinator, Action Against Hunger PakistanMrMarkButtle,Senior Humanitarian WASH Advisor, Save the ChildrenMsMarieTheresBenner,Senior Health Advisor, Malteser InternationalMsMeganWilson-Jones,Policy Analyst: Health & Hygiene, WaterAidMrDrMohammadMonirulHasan,Centre for Development Research (ZEF), University of BonnMsMonicaRamos,WASH and Shelter Expert, Middle East and Eurasia, ECHOMsStephanieStern,Responsable ACF-LAB, ACF-FranceMrStephanSimon,Advisor Basic Infrastructure, WASH, Deutsche WelthungerhilfeMrTanguiLeziart,WASH Programme Manager, Action Against Hunger MrTomDavis,Global Health/behaviour Change consultant and former Chief Programme Officer of Food for the Hungry


hoW to use this guidebook

Undernutrition is a multi-sectoral problemwith multi-sectoral solutions. By applying integrated approaches, the impact,coherenceandefficiencyoftheactioncanbeimproved.

ThisoperationalguidebookdemonstratestheimportanceofbothsupplementingnutritionprogrammeswithWASHactivitiesandadaptingWASHinterventionstoincludenutritionalconsiderationsi.e.makingthemmorenutrition-sensitiveandimpactfulonnutrition.IthasbeendevelopedtoprovidepractitionerswithusableinformationandtoolssothattheycandesignandimplementeffectiveWASHandnutritionprogrammes.Apart fromencouragingthedesignofnew integratedprojects, theguidebookprovidessupportforreinforcingexistingintegratedinterventions.Itdoesnotprovideastandardapproachorstrictrecommendations,butratherideas,examplesandpracticaltoolsonhowtoachievenutritionandhealthgainswithimprovedWASH.IntegratingWASHandnutritioninterventionswillalwayshavetobeadaptedtospecificconditions,opportunitiesandconstrainsineachcontext.

Theguidebookprimarilyaddressesfieldpractitioners,WASHandNutritionprogrammemanagersworking inhumanitariananddevelopmentcontexts,andrespondstotheneedformorepracticalguidanceonWASHandnutritionintegrationatthefieldlevel.Itcanalsobeusedasapracticaltoolfordonorsandinstitutions(suchasministriesofhealth)toprioritisestrategicactivitiesandfundingoptions.

THe CONTeNT Is ORGaNIzed as fOllOws

chAPter 1outlinesthebasicsofundernutritionandprovidesabriefoverviewofthekeyconceptsrelevantforWASHandNutritionintegratedprogramming.

chAPter 2 providestherationalebehindlinkingnutritionalstatuswithWASHenvironmentandexplainshowWASHinterventions,bypreventinginfectionanddisease,helpreduceundernutrition.Ashortsummaryofexistingevidence-basedknowledgeispresentedinthisChapter.

chAPter 3 isorganizedaroundthefivepillarsofWASH’Nutritionstrategy.ItgivesoperationalguidanceandadviceonhowtointegrateWASHandnutritioninterventions,highlightingpossiblechallengesandproposingstrategiesforovercomingthem.

chAPter 4 describesapractical implementationof integratedactivitiesatdifferent levels(household,community,national)andindifferentsettings(healthandnutritioncentres,schools).SpecialattentionisgiventointegratingWASHandNutritioninemergencycontexts.

chAPter 5 proposes a framework formonitoring andevaluating integrated interventions, togetherwith a setofindicatorsthatcanbeusedtomeasureprogressandimpact.

chAPter 6coversadvocacyforWASHandnutritionintegration,communication,capacity-buildingforprojectstaffandtheoperationalresearch.

the ProgrAmmAtic resources section contains a collection of practical tools and examples from fieldprojectstohelpintegrationeffortsateachphaseofaclassicalprojectcycle.

Theguidebookalsocontainsanumberofnotes,boxeswithtipsandfurthercomments, linkstowebpagesandsuggestedreading.Throughouttheguidebookyouwillfindpracticalexamplesfromthefield(casestudies),collectedfromACFmissionsandthecontributors.

Youwillfindlistsoffigures,boxesandtablesp.10.

9WAsh’nutrition


foreWord

Undernutrition remains a significant global public health threat. It affects millions of children and contributes to an estimated 3.1 million child deaths each year, accounting for over a third of all deaths of children. Adequate nutrition in early childhood is essential for healthy physical growth and brain development. Nutritional deficiencies during this period can not only result in disease and death, but also can have long term consequences on cognitive and social abilities, school performance and work productivity.

When children are undernourished they are more likely to suffer from diarrheal diseases and other infections. Emergency and development settings where undernutrition is high often have inadequate and unsafe water, sanitation and hygiene (WASH) services which further compounds the problem. The evidence, although limited, does indicate a clear link between WASH and nutrition outcomes, with, for example, an association between open defecation and stunting.

Proven, simple interventions exist to prevent undernutrition and diarrhea, even in settings that are challenged by poor sanitation, lack of hygiene, and unsafe drinking water. The 2015 WHO/UNICEF/USAID document, Improving nutrition outcomes with better water, sanitation and hygiene: Practical solutions for policy and programmes, serves as an important foundation document for understanding the evidence, the interventions and approaches for joint WASH and nutrition actions. This practical field guide by ACF complements this initial publication by providing more detailed, frontline examples from over 30 countries on when, where and how to integrate efforts. It is targeted at humanitarian and development workers looking for simple but effective strategies for achieving nutrition targets, in part, through better WASH.

Addressing undernutrition and meeting the 2025 Global Nutrition Targets will require a multi-sectoral approach with a strengthened focus on improving WASH. Furthermore, the Development Goals, including Goal 6 on Water and Sanitation, Goal 3 on Health and Goal 17 on Partnerships provide an opportunity to target, more effectively, resources and attention on the benefits of safe WASH for nutrition and health, and development more broadly. In short, no child ought to suffer from undernutrition and through smart, targeted joint action on WASH and nutrition, millions of deaths can be prevented.

MargaretMontgomery,Water, Sanitation, Hygiene and Health, WHO

ZitaWeisePrinzo,Nutrition for Health and Development, WHO


list of figuresFigure 1:DIFFERENTTYPESOFUNDERNUTRITION 17

Figure 2: CONCEPTUALFRAMEWORKOFUNDERNUTRITION 19

Figure 3: UNDERNUTRITIONTHROUGHOUTTHELIFECYCLE 21

Figure 4: NUTRITION-SPECIFICANDNUTRITION-SENSITIVEINTERVENTIONS 22

Figure 5: NUTRITIONSECURITYAPPROACH 23

Figure 6: GLOBALTRENDSINCHILDSTUNTINGANDWASTING 27

Figure 7: RELATIONSHIPBETWEENPOORWASHANDCHILDUNDERNUTRITION 33

Figure 8: MEDIANAGE-SPECIFICINCIDENCESFORDIARRHEALEPISODESPERCHILDPERYEARFROMTHREEREVIEWSOFPROSPECTIVESTUDIESINDEVELOPINGAREAS 35

Figure 9: VICIOUSCYCLEBETWEENINTESTINALINFECTIONSANDUNDERNUTRITION 35

Figure 10: DIFFERENCEBETWEENHEALTHY(LEFT)ANDEED-INFECTEDINTESTINE(RIGHT) 36

Figure 11: REDUCTIONINDIARRHEALMORBIDITY 38

Figure 12: THEF-DIAGRAM-Fecal-oralrouteofdiseasetransmissionandhowWASHprovisioncanpreventit 39

Figure 13: EFFECTOFIMPROVEMENTSINDRINKINGWATERANDSANITATIONONDIARRHEADISEASERISK 40

Figure 14: INCREASINGLEVELSOFMULTI-SECTORALINTEGRATION 46

Figure 15: RELEVANTSTAKEHOLDERSFORWASHANDNUTRITIONINTEGRATION 60

Figure 16: HUMANITARIANCLUSTERSANDTHEIRCOORDINATION 61

Figure 17: ALLOCATEAPROTECTEDSPACEFORCHILDRENTOPLAY,LIMITINGTHELIKELIHOODOFTHEMINGESTING SOILORANIMALFECES 75

Figure 18: THECLEANHOUSEHOLDAPPROACH 75

Figure 19: ACOUNSELLINGCARDHIGHLIGHTSWHENTOWASHHANDSWITHSOAP 77

Figure 20: POSTERUSEDTODISCUSSKEYFOODHYGIENEPRACTICESBYACFCHAD 81

Figure 21: GLOBALCOVERAGEOFWASHINHEALTHCAREFACILITATES 95

Figure 22: THEFITFORSCHOOLACTIONFRAMEWORK 101

Figure 23: HOLISTICAPPROACHTOWASHANDNUTRITIONINTEGRATION 105

Figure 24: DRMCYCLE,CONTINUUMANDCONTIGUUM 109

list of tAblestAble 1: CUT-OFFVALUESANDANTHROPOMETRICINDICATORSOFUNDERNUTRITION 18

tAble 2: MORTALITYRISKSFORWASTINGAND/ORSTUNTING 20

tAble 3: NON-ExHAUSTIVEExAMPLEOFWASHINTERVENTIONS 26

tAble 4: INCORPORATINGWASHELEMENTSINTONUTRITIONASSESSMENTSANDVICEVERSA 50

tAble 5: COMMONBARRIERSANDCHALLENGESINWASHANDNUTRITIONINTEGRATION 53

tAble 6: ILLUSTRATIVECRITERIAFORPOPULATIONTARGETING 54

tAble 7: TENSTEPMODELFORASSISTINGBEHAVIOURCHANGE(ABC) 58

tAble 8: WASHMINIMUMPACKAGEFORHOUSEHOLDS 63

tAble 9: WASH MINIMUMPACKAGEFORHEALTHANDNUTRITIONCENTRES 65

tAble 10: WASH MINIMUMPACKAGEFORMOBILECLINICS 67

tAble 11: INTEGRATINGWASHINTONUTRITIONCOUNSELLINGANDHEALTHPROMOTION 86

tAble 12: WHODEFINITIONOFENVIRONMENTALMANAGEMENT 91

tAble 13: WHOSTANDARDSONWATER,SANITATIONANDHYGIENEINHEALTHCARE 96

tAble 14: ExCRETADISPOSALOPTIONSFORYOUNGCHILDRENINEMERGENCIES 112

tAble 15: EVALUATIONOFANINTEGRATEDPROJECT 122

tAble 16: ADVOCACYTOOLSFORPROMOTINGWASHANDNUTRITIONINTEGRATION 133

11WAsh’nutrition


list of boXesboX 1: DESIGNCHARACTERISTICSOFNUTRITION-SENSITIVEINTERVENTIONS 23

boX 2: COMMUNITYMANAGEMENTOFACUTEMALNUTRITION(CMAM)APPROACH 24

boX 3: WASH’NUTRITIONTARGETING 45

boX 4: SEASONALCALENDAR 49

boX 5: DIFFERENTAGESTAGESANDWASHPROGRAMMING 55

boX 6: IMPROVINGCHILDREN’SPARTICIPATIONINWASHBEHAVIOURCHANGEPROGRAMMES 57

boX 7: ASSISTINGBEHAVIOURCHANGE(ABC)MODEL 58

boX 8: BABYWASHMESSAGES 74

boX 9: 5CRITICALSTIMESFORHANDWASHINGWITHSOAP 77

boX 10: 5KEYSTOSAFERFOODBYTHEWHO 80

boX 11: BREASTFEEDING–THEULTIMATEHYGIENEINTERVENTION 81

boX 12: LINKINGWASHANDNUTRITIONWHENDELIVERINGOVERALLCOMMUNITYSERVICES 84

boX 13: REDUCINGANIMALWASTECONTAMINATION 93

boX 14: MAINHYGIENEPROMOTIONMESSAGESUSEDINTHEACFMISSIONINCHADDURINGTHEWEEKLYHYGIENE PROMOTIONSESSIONSINHEALTHCENTRES 98

boX 15: PUBLICHEALTHAPPROACHTONUTRITION 105

boX 16: OVERCOMINGTHEHUMANITARIAN-DEVELOPMENTDIVIDEWHENADDRESSINGUNDERNUTRITION 108

boX 17: CHILD-TO-CHILDAPPROACHOVERVIEW 113

boX 18: MONITORINGINDICATORSSUGGESTEDBYWASH’NUTRITIONSTRATEGY 120

boX 19: EFFECTIVENESSOFADDINGAHOUSEHOLDWASHCOMPONENTTOAROUTINEOUTPATIENTPROGRAMME OFSEVEREACUTEMALNUTRITION 127

boX 20: INTERNATIONALDAYSOFSHAREDINTERESTFORWASHANDNUTRITIONSECTORS 130

boX 21: MISSINGINGREDIENTSREPORT–WATERAIDANDSHARECONSORTIUM 135

boX 22: GERMANY’SSPECIALINITIATIVE“ONEWORLDNOHUNGER” 137

list of mApsmAP 1: DIARRHEADEATHSUNDER5 28

mAP 2: WASTINGCHILDRENBYREGION 28

mAP 3: PERCENTAGEOFCHILDRENUNDER5WHOARESTUNTED 28

mAP 4: OVERLYINGGAMRATESWITHACCESSTODRINKINGWATERINCHAD 48

mAP 5: NIGER,2000:STUNTING,DIARRHEAANDWASH 142


list of AcronYmsAbc ASSISTINGBEHAVIOURCHANGEAri ACUTERESPIRATORYINFECTIONSAscAo VILLAGE-BASEDMANAGEMENTASSOCIATIONSbmgF BILLANDMELINDAGATESFOUNDATIONbmZ GERMANFEDERALMINISTRYFORECONOMICCOOPERATIONANDDEVELOPMENTccts CONDITIONALCASHTRANSFERScgv CAREGROUPVOLUNTEERchAst CHILDRENHYGIENEANDSANITATIONFORTRANSFORMATIONclts COMMUNITYLEADTOTALSANITATIONcmAm COMMUNITYMANAGEMENTOFACUTEMALNUTRITIONDFiD BRITISHDEPARTMENTFORINTERNATIONALDEVELOPMENTDhs DEMOGRAPHICHEALTHSURVEYSecho EUROPEANCOMMISSION,DIRECTORATE-GENERALFOREUROPEANCIVILPROTECTIONAND

HUMANITARIANOPERATIONSecosAn ECOLOGICALSANITATIONeeD ENVIRONMENTALENTERICDYSFUNCTIONenn EMERGENCYNUTRITIONNETWORKevis ExTREMELYVULNERABLEINDIVIDUALSeWP ENDWATERPOVERTYFchvs FEMALECOMMUNITYHEALTHVOLUNTEERSFh/m FOODFORTHEHUNGRY/MOZAMBIqUEFti FAECALLYTRANSMITTEDINFECTIONSgAc GLOBALAFFAIRSCANADAgAm GLOBALACUTEMALNUTRITIONgDP GROSSDOMESTICPRODUCTgems GLOBALENTERICMULTI-CENTRESTUDYgis GEOGRAPHICINFORMATIONSYSTEMgnc GLOBALNUTRITIONCLUSTERgWn GERMANWASHNETWORKhFA HEIGHTFORAGEhh HOUSEHOLDShhWt HOUSEHOLDWATERTREATMENThmis HEALTHMANAGEMENTINFORMATIONSYSTEMhWts HOUSEHOLDWATERTREATMENTANDSAFESTORAGEicn2 SECONDINTERNATIONALCONFERENCEOFNUTRITIONiDA IRONDEFICIENCYANAEMIAiDPs INTERNALLYDISPLACEDPEOPLEiYcF INFANTANDYOUNGCHILDFEEDINGiYFc INFANTANDYOUNGCHILDRENFEEDINGKAP KNOWLEDGE,ATTITUDEANDPRACTICElbW LOWBIRTH-WEIGHTlrrD LINKINGRELIEF,REHABILITATIONANDDEVELOPMENTmAm MODERATEACUTEMALNUTRITIONmDg MILLENNIUMDEVELOPMENTGOALSmirA MULTI-SECTORINITIALRAPIDASSESSMENTmou MEMORANDUMOFUNDERSTANDINGmsF MéDECINSSANSFRONTIèRESmuAc MID-UPPERARMCIRCUMFERENCEmus MULTIPLE-USEWATERSERVICES

13WAsh’nutrition


ncD NON-COMMUNICABLEDISEASEngo NON-GOVERNMENTALORGANIZATIONntD NEGLECTEDTROPICALDISEASESntu NEPHELOMETRICTURBIDITYUNITSors ORALREHABILITATIONSOLUTIONPeFsA v PAKISTANEMERGENCYFOODSECURITYALLIANCEVPhAst PARTICIPATORYHYGIENEANDSANITATIONTRANSFORMATIONPlW PREGNANTLACTATINGWOMENProconu PROGRAMMECOMMUNAUTAIRENUTRITIONNELrutF READY-TO-USETHERAPEUTICFOODSsAm SEVEREACUTEMALNUTRITIONsbcc SOCIALBEHAVIOURCHANGECOMMUNICATIONSsDc SWISSAGENCYFORDEVELOPMENTANDCOOPERATIONsDg SUSTAINABLEDEVELOPMENTGOALSsiDA SWEDISHINTERNATIONALCOOPERATIONAGENCYslts SCHOOL-LEDTOTALSANITATIONsm SANITATIONMARKETINGsun SCALINGUPNUTRITIONsusAnA SUSTAINABLESANITATIONALLIANCEsWA SANITATIONANDWATERFORALLPARTNERSHIPStDh TERREDESHOMMEStot TRAININGOFTRAINERStssm TOTALSANITATIONANDSANITATIONMARKETINGunhcr UNITEDNATIONSHIGHCOMMISSIONERFORREFUGEESuniceF UNITEDNATIONSINTERNATIONALCHILDRENEDUCATIONFUNDurenAs OUTPATIENTNUTRITIONRECOVERYANDEDUCATIONUNITSvhsgs VILLAGEHEALTHSUPPORTGROUPSWAsh WATER,SANITATIONANDHYGIENEWFA WEIGHTFORAGEWFh WEIGHTFORHEIGHTWFP WORLDFOODPROGRAMMEWho WORLDHEALTHORGANIZATION


Jova

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, 201

5

1the bAsics

of undernutrition and WAsh

1. defining undernutrition

2. the mAin cAuses of undernutrition

3. the “1,000 dAYs” WindoW of opportunitY

4. undernutrition consequences

5. Addressing undernutrition

6. globAl trends in undernutrition And WAsh

15WAsh’nutrition


the

bA

sics

of

un

der

nu

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ion

an

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Ash


end hunger, Achieve food securitY And improved nutrition And promote sustAinAble Agriculture

ensure heAlthY lives And promote Well-being for All At All Ages

ensure AvAilAbilitY And sustAinAble mAnAgement of WAter And sAnitAtion for All

WAsh’nutrition illustrAtes the link betWeensustAinAble development goAls 2, 3 And 6

17WAsh’nutrition


1. defining undernutrition

Defined by UNICEF as “the outcome of insufficient food intake and repeated infectious diseases,“ undernutrition isoneoftheworld’smostseriousbut leastaddressedproblemswithdirectshort-and long-termhealth effects. Undernutrition includes being underweight for one’sage, dangerously thin for one’s height – wasted, too short for one’sage - stunted, and deficient in vitamins and minerals - micronutrientdeficiencies.1 These conditions often overlap - for example, a stuntedchild may also bewasted and have micronutrient deficiencies, whichincreasesariskofmorbidityandmortality.2

Figure 1: DIFFERENTTYPESOFUNDERNUTRITION

Normal height for age

normAl WAstingLow weight for height

underWeightLow weight for age

stuntingLow height for age

Source: World Vision (2015), “Definitions of hunger”

Acute undernutrition is indicated by a lowweight-for-height(WFH), when compared to the WHO growth standards (socalled“Zscores”),3and/orpresenceofbilateraledemasand/orMUAC


chronic undernutrition or stunting is indicatedbya lowheight-for-age (HFA).Asopposedtoacuteundernutritionwhichreflects recent nutritional status, chronic undernutrition is a process occurring over longer term in the period betweenconceptionand24monthsofage.Itisaconsequenceofprolongedorrepeatedepisodesofnutritionaldeficiencies(energyormicronutrients)andcanalsoreflectexposuretorepeated infectionorother illnessesthroughouttheearlyyearsof life,compromisingthegrowthofachild.5

underweight isacompositeformofundernutritiondefinedbya lowweight-for-age (WFA)whencomparedtotheWHOgrowthstandards.Underweight iseasier tomeasurethanweight-for-heightorheight foragebecause itdoesn’t requireaheightmeasurement,butitisgenerallyconsideredinferiortothemeasuresaboveasitdoesn’tindicateifachildiswastedorstunted.

Micronutrient deficiencies,alsoknownas“hidden-hunger”,occurwhenthebodydoesnothavesufficientamountsofvitaminormineral due to insufficient dietary intake and/or insufficient absorption and/or suboptimal utilizationof thevitamin ormineral.WHOranksdeficienciesofzinc,ironandvitaminAinthetop10causesofthediseaseburdenindevelopingcountries.Micronutrientdeficienciesaffectthesurvival,health,developmentandwell-beingofthoseaffected.6

All forms of undernutrition can and should be prevented.

tAble 1: CUT-OFFVALUESANDANTHROPOMETRICINDICATORSOFUNDERNUTRITION

Anthropometric indicators used to measure child growth and nutritional statusPrevalence cut-off

values of public health significance

AcuteunDernutrition

sAmWFHindicator<-3Z-scoresoftheWHOGrowthstandardsand/orMUACbelow115mmand/orpresenceofedema

ReferstoGAM7:

<5%:Acceptable

5-9%:Medium

10-14%:High

≥15%:Veryhigh

*SHPEREstandardforemergencies:SAM>2%

mAmWFHZ-score<-2but>-3115mm≤MUAC<125mmwithoutedema

stunting

severe HFAindicator<-3Z-scoresoftheWHOGrowthstandards <20%:Low

20-29%:Medium

30-39%:High

≥40%:Veryhigh moderate HFAindicator<-2Z-scoresoftheWHOGrowthstandards

unDerWeight WFAindicator<-2Z-scoresoftheWHOstandards

<10%:Low

10-19%:Medium

20-29%:High

≥30%:Veryhigh

micronutrient DeFiciencies

Usuallymeasurethroughbiomarkers,whichrequirestakingabloodand/orurinesample

Dependsonadeficientmineral/vitamin

Adapted from: WHO (2010) “Nutrition Landscape Information System”

5-Ibid6-Ibid7-GlobalAcuteMalnutrition(GAM)isthesumoftheprevalenceofsevereacutemalnutrition(SAM)andmoderateacutemalnutrition(MAM)atapopulationlevel

19WAsh’nutrition


2. the mAin cAuses of undernutrition

The determinants of undernutrition are complex and nutritionalstatusisdependentonawiderangeofdiverseandinterconnectedfactors.Atthemostimmediatelevel,undernutrition is the outcome of inadequate dietary intake and repeated infectious diseases.8 Itsunderlyingdeterminantsincludefoodinsecurity,inappropriatecare practices, poor access to health care and an unhealthy environment, including inadequate access to water, sanitation and hygiene.Allthesefactorsresultintheincreasedvulnerabilityto shocks and long-term stresses. The basic determinants ofundernutrition are rooted in poverty and involve interactionsbetween social, political, demographic and economic conditions(seeFigure2).9

Figure 2: CONCEPTUALFRAMEWORKOFUNDERNUTRITION

sho

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s, s

eAso

nA

litY

inADeQuAte DietArY intAKe DiseAse

Short-terM conseQuences:

Mortality,morbidity,disability

MediuM-terM conseQuences: Adultsize,intellectualability,economicproductivity,reproductiveperformance,metabolic

andcardio-vasculardiseases

mAternAl AnD chilDunDernutrition

economic, PoliticAl AnD iDeologicAl structures

PotentiAl resources Human,natural,physical,socialandfinancial

FormAl AnD inFormAl institutions,includingmarketsandserviceproviders

Pooraccesstosufficient,safeandnutritiousfood.

Pooraccesstoqualityhealthservices.

Unhealthysanitaryenvironment.

Inadequatematernalandchildcareandfeedingpractices.

Source: ACF (2012) “The Essential: Nutrition and Health”Adapted from: UNICEF Conceptual Framework on causes of undernutrition (1990)

8-WHO(2005)“Malnutrition”9-ACF(2011)“Maximizingthenutritionalimpactoffoodsecurityandlivelihoodsinterventions”

Undernutrition has often been viewed as a problem of limited food availability and solutions for addressing

undernutrition have often focused on increasing food

production. Such a perception is very simplistic and

ignores a wide range of contributing factors which

nutrition interventions need to address in order to

achieve tangible results. Meaningful nutrition and

WASH integration requires a good understanding of

complex causes and determinants of undernutrition

(ACF, 2014).

no

te


Undernutritionisalsolinkedtostructuralinjustice.Childrenare1.5to2timesmorelikelytobestuntedwhenlivinginruralareas,inthepooresteconomicquintilesandinregionswherewomen’sstatus/educationislowest.Thisstemsfromthefactthattheytendtobedisadvantagedintermsofaccesstohealthcare,water,sanitationandhygiene,aswellasnutritiousfoodandhealth-relatedinformation.10

To find out more about different forms of undernutrition and better understand the differencebetweenchronicandacuteundernutrition,pleasevisit:http://www.unicef.org/nutrition/training/2.3/1.html - UNICEF online training

Tobetterunderstandmultiplecausesofundernutrition,pleasevisit:http://www.unicef.org/nutrition/training/2.5/1.html - UNICEF online training

leaRNMORe

3. the “1,000 dAYs” WindoW of opportunitY

Whileitisrecognizedthatnutritionisimportantthroughoutaperson’slife,themostcriticalperiodinaperson’sdevelopmentarethefirst1,000days-beginningwithconception,throughoutamother’spregnancyanduntiltheageoftwo.Thisbasicallymeansthatundernutritioncanalreadybeginwiththeundernourishedmotherwhocannotprovideherchildwithsufficientnutrientsatthefetalstage,assheherselfhasnotbenefitedfromoptimalnutrition.Currentresearch11appearstovalidatetheviewthatunsafedrinkingwater,poorsanitationandinadequatehygienesignificantlyincreasetheriskofundernutrition,inparticularduring thiscriticalwindowof1,000days,whenachild ismorevulnerable to theadverseeffectsofFaecallyTransmittedInfections(FTI)12.Damagedonetoachild’sphysicalgrowth,immunesystemandbraindevelopmentduringthisperiodisusuallyirreversible.13

4. undernutrition consequences

An estimated 45% of the global under-five death burden is due to undernutrition in all its forms, including sub-optimalbreastfeeding.14The increasedrisksofdeathanddiseases (diarrhea,malaria,etc.)associated individuallywithwastingandstuntinghavebeenwidelyinvestigatedanddocumented.15Bothwastingandstuntingareassociatedwithincreasedriskofmortalitywithevenmilddeficitsbeingassociatedwithhigherriskofdyingandincreasingprogressivelywiththedegreeofthedeficit.Thismeansthatanychildexperiencingadegreeofwastingorstuntinginanycontextisatheightenedriskofdying.Importantly,thechildwhoisbothstuntedandwasted(evenmoderately)hasthehighesthazardofdeath,evenhigherthanforseverewastingindividually.16

tAble 2: MORTALITYRISKSFORWASTINGAND/ORSTUNTING

MORTALITy RISkS Wasted children stunted children Both wasted and stunted children

multiplyingeFFects

moDerAte 3to3,4 1,6to2,312,3

severe 9,4to11,6 4,1to5,5

Source: ENN, USAID (2014) “Technical Briefing Paper, Associations between Wasting and Stunting,policy, programming and research implications”

10-GenerationNutrition(2014)“Undernutrition:TheBasics”11-Checkleyetal(2008)“Multi-countryanalysisoftheeffectsofdiarrheaonchildhoodstunting”12-ChambersandVonMedeazza(2017)13-ThousandDays(2015)“Why1,000days?”14-TheLancet(2013)“MaternalandChildUndernutritionSeries”15-Collins(2007);Black,Allenetal.(2008);McDonald,Olofinetal.(2013)16-McDonald,Olofinetal.(2013)

21WAsh’nutrition


Chronicundernutritionimpairschildgrowth,cognitiveandphysicaldevelopment,weakenstheimmunesystemandincreasesthe risk ofmorbidity andmortality. Undernourished children have a higher risk of suffering from chronic diseases (suchasdiabetes and cardiovascular disease) in adulthood.17Maternal undernutrition, especially irondeficiency anemia (IDA) isassociatedwithpoorreproductiveperformance,ahigherproportionofmaternaldeaths,ahighincidenceoflow-birth-weight(LBW),andintrauterineundernutrition.18Recentstudieshavealsoconfirmedanassociationbetweenstuntingandreduced school attendance and performance,whichhaslongertermimplications,atbothmicroandmacrolevels.Undernourishedchildrenareat risk of losing more than 10% of their lifetime earnings potential.19 the economic cost of undernutrition is estimated at 2 to 8 % of Gross domestic product (Gdp),20 indicating that undernutrition reduces overall economicdevelopment.

Whensevereacutemalnutritionispresent,thebodygivesprioritytothefunctioningofvitalorgans(brain,heartandlungs)topreservethem.Thefunctioningofotherorgansisthusreduced.Thisphenomenongenerates,amongothers,aslowdownofthedigestivesystemandtheabsorptionofnutrientscannotbeoptimal.Ifthiscycleisnotstoppedintime,thebody’svitalorgans(heart,kidneys,liver,stomach)graduallyslowdowntheiroperationuntildeathoccurs.21

Undernutritionperpetuatesitselfinaviciouscyclethatlastsbeyondthelifecycleofanindividual(Figure3).

Figure 3: UNDERNUTRITIONTHROUGHOUTTHELIFECYCLE

Mortalityrate

Impairedmentaldevelopment

bAbYLowBirthWeight

Untimely/inadequatecomplementaryfoods

Frequentinfections

Inadequatefood,healthandcare


Reducedmentalcapacity

chilDstunted

Reducedmentalcapacity

ADolescentstunted


Highermaternalmortality

elderlyMalnourished

PregnAncYLowWeightGain

MalnourishedADults


FetalUndernutrition

Reducedcapacitytocareforchild

Inadequategrowth

Source: ACC/SCN fourth report on the World Nutrition Situation (2000)

Maternalundernutritionleadstopoorfetaldevelopmentandhigherrisksofcomplicationsinpregnancy.Poornutritionoftenstarts in the uterus and extends, particularly for girls andwomen,well into adolescent and adult life.Womenwhowereundernourishedasgirlsare likelytobecomeundernourishedmothers,whogivebirthtoLBWbabies, leadingtoa vicious intergenerational cycle.LBWinfants,whosufferedfromintrauterinegrowthretardation,areathigherriskofdying intheneonatal period or later infancy. If they survive, they are unlikely to catch up on this lost growth and aremore likely toexperience avarietyof developmental deficits.AnLBW infant ismore likely tobeunderweight or stunted in early life.22 Therefore,undernutritionanditsconsequencesrepeatthemselves,generationaftergeneration.

17-ACF(2014)“NutritionSecurityPolicy”18-ACF(2011)“Maximizingthenutritionalimpactoffoodsecurityandlivelihoodsinterventions”19-TheWorldBankGroup(2011)“Repositioningnutritionascentraltodevelopment”20-ACF(2014)“NutritionSecurityPolicy”21-ACF(2012)“TheEssential:nutritionandhealth”22-ACF(2012)“TheEssential:nutritionandhealth”


5. Addressing undernutrition

A long term, sustainable and at-scale impact on undernutrition cannot be achievedwithout tackling all context-specific immediate and underlying causes of undernutrition.For this,acoherentandcoordinatedmulti-sectoralapproach linkingpreventiveandcurativeactionsandstrategiesisneeded.

5.1. NuTRITION-sPeCIfIC aNd NuTRITION-seNsITIve INTeRveNTIONs

Recentliteratureandprojectreviewshavehighlightedinterventionprinciplesandstrategieswithhighpotentialtoaddressundernutrition,distinguishingbetweennutrition-specificandnutrition-sensitiveinterventions.

The 2013 Lancet Series identified a set of effective, nutrition-specificinterventions that, if brought to scale, could save millions of lives andcontribute to long-term health and development. If these ten proveninterventions were scaled-up from the existing population coverage to90%, an estimated 900,000 lives could be saved in 34 high nutrition-burdencountries(where90%oftheworld’sstuntedchildrenlive)andtheprevalenceofstuntingcouldbereducedby20%andthatofseverewastingby60%.23

Figure 4: NUTRITION-SPECIFICANDNUTRITION-SENSITIVEINTERVENTIONS

Source: Lancet Series, 2013

Whilethesewouldbeextremelysignificantactions,itisalsoclearthatwithouteffortstoaddressindirectorunderlyingdrivers

23-TheLancet(2013)“Evidence-basedinterventionsforimprovementofmaternalandchildnutrition:whatcanbedoneandatwhatcost?”

defininG nutrition-Specific And nutrition-SenSitiVe

interventions (Ruel et al., 2013)

nutrition-specific interventions: Interventionsthataddressthe

immeDiAtedeterminantsoffetalandchildnutritionanddevelopment.

nutrition-sensitive interventions: Interventionsthataddressthe

unDerlYingdeterminantsoffetalandchildnutritionanddevelopment.

23WAsh’nutrition


of undernutrition, the global problemwill not be resolved.Nutrition-sensitive interventions inwater, sanitation, hygiene,agriculture,health,socialsafetynets,earlychilddevelopment,andeducation,tonameafew,havetheenormouspotentialtocontributetoreducingundernutrition.24

WASH interventions, among others, represent a key nutrition-sensitive approach in preventing undernutrition. As oftenimplementedinalargescale,theycanserveasadeliveryplatformforenhancingthecoverageandeffectivenessofnutrition-specificinterventions.25However,WASHprogrammesarenotalwaysdesignedasnutrition-sensitive.Toeffectivelycontributetoachievingnutritionoutcomes,WASHprogrammesshouldhavecertaindesigncharacteristics(Box1).

boX 1: DESIGNCHARACTERISTICSOFNUTRITION-SENSITIVEINTERVENTIONS

1 targeting on the basis of nutritional vulnerability. Forexample,targetgroupswiththehighestundernutritionrates,groupsthatarethemostvulnerabletoundernutrition(childrenunderfive,pregnantwomen),populationsfacingstressrelatedtofoodsecurityorothershocks.

2 identifying nutrition goals to maximize opportunities. Whichactivitiescanimpactonnutrition?Howaretheplannedactivitiesgoingtoleadtoachangeinthenutritionalstatus?Designingappropriateindicatorsandobjectivestomonitorandevaluatetheimpactisessential.

3 engaging women and including interventions to protect and promote their nutritional status,well-being, social status,decision-makingandoverallempowermentaswellastheirabilitytomanagetheirtime,resourcesandassets.

4 including nutrition promotion and behaviour change strategies.

5 considering alternativestominimizeunintendednegativeconsequencesandmaximizethepositiveimpactonnutrition.Appropriatetiminganddurationoftheinterventiontoinfluencenutritionalstatus.

Source: ACF (2014) “Nutrition security policy” & World Food Programme (2014)“Nutrition sensitive programming: What and why”?

5.2. NuTRITION seCuRITY aPPROaCH

This guidebook endorses the World Bank definition ofnutrition security defined as “the ongoing access to the basic elements of good nutrition, i.e., a balanced diet, safe environment, clean water, and adequate health care (preventive and curative) for all people, and the knowledge needed to care for and ensure a healthy and active life for all household members”.26 Therefore,nutritionsecuritygoesbeyondthetraditionalconceptoffoodsecurity and recognizes that nutritional status is dependenton awide and multi-sectoral array of factors. A householdhasachievednutritionsecuritywhenithassecureaccesstofood coupledwith a proper sanitary environment, adequatehealthservices,andknowledgeablecaretoensureahealthylifeforallhouseholdmembers(Figure5).27Nutritionalsecuritytherefore encourages better integrationof actions.Amulti-sectoral approach is needed to achieve it.

24-ACF(2014),“NutritionSecurityPolicy”25-Ibid26-TheWorldBank(2013)“Improvingnutritionthroughmulti-sectoralapproaches”27-ACF(2011),“Maximizingthenutritionalimpactoffoodsecurityandlivelihoodsinterventions”

Figure 5: NUTRITIONSECURITYAPPROACH

FOODSECURITY

HEALTHYENVIRONMENT

ADEqUATEEDUCATION

ADEqUATECARING PRACTICES

HEALTHSECURITY

NUTRITIONSECURITY

Source: ACF (2014) “Nutrition Security Policy”


the WASh sector plays an important role in ensuring nutrition security, given that the status ofWASH impacts theavailability,access,stabilityorresilienceandutilizationoffoodresources.Inaddition,suitableWASHconditionsarenecessaryforensuringahealthyenvironment,accesstohealthservices,adequatecaringpracticesandeducation.

5.3. NuTRITION PROGRaMMING

Whilethereisawiderangeofnutritioninterventionsthatcouldbeappliedtodiagnoseandtreatundernutrition,preventionistheprimaryobjectivefortacklingundernutritioninallitsforms.

ChildrenwhoaresufferingfromsAm need treatment services,i.e.accesstoout-patienttherapeuticprogrammesinahealthcentre or, if they havemedical complications (pneumonia, fever, dysentery, etc.), in-patientmanagement.28 For example,with theCMAMapproach (seeBox2),approximately90%ofSAMcasescanbe treatedathome,withpatients receivingready-to-use therapeutic food combinedwith regular visits to the closest health centre. The CMAM approach includesmAm treatmentaswell–buttreatingMAMwithready-to-usesupplementaryfoodshouldbeconsideredonlyinspecificcontexts likeemergencies andpopulationdisplacements and shouldno longerbe consideredas theonlyway to treatorpreventmoderateacutemalnutrition.Approachessuchascashtransfersorfoodvoucherscanbeusefulalternativeswhenfoodisavailableinthelocalmarkets.Nutrition-specificactivitiessuchascounsellingandsupportforcontinuedbreastfeeding,appropriatecomplementaryfeedingfrom6monthsupto2years,vitaminAsupplementation,anddewormingarepartofthetreatmentandcanhelppreventbothSAMandMAM.Theseactivitiesshouldbeaccompaniedwithnutrition-sensitiveWASHinterventions,socialsafetynets,supportformaternalmentalhealth,etc.soastoensureoptimallong-termpreventionofacuteundernutrition.

Stuntingcannotbe “treated”29and itshould thereforebepreventedcontinuously throughout the most critical period of humandevelopment–thefirst1,000daysfromconceptiontoachild’ssecondbirthday. Some examples of prevention activities include: improvingnutritionforpregnantandlactatingwomen,promotingearlyinitiationofbreastfeedingwithin1hourofbirth,exclusivebreastfeedingforthefirst6monthsoflife,adequatecomplementaryfeeding,micronutrientsupplementation to women of reproductive age, pregnant womenand children, etc.30 Programmes aiming at decreasing chronicundernutritionratesneedtobelongtermandcomprehensive,includingboth community-based approaches and governance issues at thenational level.Waterandsanitationprogrammes, IYCFprogramming,micronutrientinterventions,agricultureandfoodsecurityinterventions,advocacy on nutrition, women’s empowerment, education, familyplanning,andsoon,allcontributetostunting-reductionefforts.31

boX 2: COMMUNITYMANAGEMENTOFACUTEMALNUTRITION(CMAM)APPROACH

CommunityManagementofAcuteMalnutrition(CMAM)isanapproachtotreatacuteundernutrition.TheCMAMapproachhasbeenlargelyscaledupsincefirstintroducedin2000andcommunity-basedtreatmentofSAMisnowincludedasastandardpartofthehealthpackageinnationalpolicy.CMAMisapplicabletobothemergencyandnon-emergencycontextswheretheprevalenceofacuteundernutritionamongchildrenunderfiveishighandaggravatingfactors(foodinsecurity,widespreadcommunicablediseases,etc.)arepresent.

28-WHO(2014)“SevereAcuteMalnutrition”29-Somecatch-upgrowthispossiblebeforetheageoftwo30-ACF(2012)“TheEssential:nutritionandhealth”31-Ibid

inFAnt AnD Young chilD FeeDing(IYCF)

Referstofeedingpracticesprovidedtochildren,frombirthuntiltheageof2.Thesedifferfromtheonesofotheragegroups,becausethenutritionneedsofinfantsandyoungchildrenaredifferent,whilethetextureoffoodsandthefrequencyoffeedinghave tobeadapted to their capacity tochewandthesizeandmaturityoftheirdigestivesystem.Optimal infant andyoung child feedingplays a decisive role in the 1,000 days criticalwindowofopportunityand iscrucial topreventstunting, as well as wasting and micronutrientdeficiencies.

25WAsh’nutrition


TheCMAMapproachhasfourcomponents:

1 communityoutreachasthebasis;

2 managementofmoderateacutemalnutrition(MAM);

3 outpatienttreatmentforchildrenwithSAMwithagoodappetiteandwithoutmedicalcomplications;and

4 inpatienttreatmentforchildrenwithSAMandmedicalcomplicationsand/ornoappetite.Integrationofin-patientandout-patientservicesforSAM,activecommunityscreening,referralandfollowupprovedtobecrucialfor increasingcoverageofSAMtreatmentservices.

The comprehensive cmAm model links with maternal, new-born, and child health and nutrition,water, sanitation and hygiene,foodsecurityandlivelihood,andothercommunityoutreachinitiatives.MoreabouttheCMAMapproach:http://www.cmamforum.org/

Micronutrient deficiencies areoftendiagnosedtoolateandcanhaveanirreversibleeffectonpeople.Thecommononesinclude iodinedeficiency,vitaminA, ironandzincdeficiencies.Effectivecontrolofmicronutrientundernutrition is likelytoinvolve both curative and preventative approaches. A number of approaches may be followed to prevent micronutrientdeficiencies,including:provisionoffreshfooditemsand/oroffortifiedfoods,distributionoffoodsupplementationproductsand/orofnutrientsupplements;promotionofrecommendedinfantfeedingpractices;ensuringadequatehealthcareandaccesstoadequatenon-fooditems.Aneffectivepreventionstrategyis likelytouseacombinationofthesedifferentapproaches.Treatmentusuallytakestheformoforalsupplementtablesorcapsulesandshouldbeaccompaniedbyagoodgeneraldietandappropriatehealthcare.32

ACFbook“TheEssential:nutritionandhealth”,availableinEnglishandFrench:http://www.actioncontrelafaim.org/fr/content/l-essentiel-en-nutrition-sante-essential-nutrition-and-health

ACFNutritionsecuritypolicy,availableinEnglish,FrenchandSpanish:http://www.actioncontrelafaim.org/en/content/acf-international-nutrition-security-policy

TheGlobalNutritionClustertoolkitcanbefoundhere:http://nutritioncluster.net/topics/im-toolkit/

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5.4. wasH PROGRaMMING

WASHincludesanumberofinterventionsthatcouldbegroupedinseveralcategories:watersupply(improvingwaterquantityandquality),sanitation(particularlysafeexcretadisposal)andhygienepromotion/education(includinghandwashing,food,personalandenvironmentalhygiene).Watersupply,sanitationandhygienearecloselylinkedandkeepingsomeoneingoodhealthdependsoneachofthesecomponentsindividuallyaswellasonmanyexistinginteractionsbetweenthem.Forexample,personal hygiene depends onwater availability; access towater greatly facilitates hygienic use of sanitation; unhygieniclatrinesthreatenthequalityofnearbywatersourcesandleadtoanincreaseinthenumberofflies;goodhygienecanpreventcontaminationaftercollectingwaterfromthesource,etc.33

Table3providesanon-exhaustivelistofWASHinterventions.Hygienepromotionactivitiesmightbethemostfeasibletointegrateandimplementjointlywithnutritionprogrammes.However,therearemanypracticalsolutionsforintegratingotherinterventionssuchassanitationandimprovingwaterqualityintonutritionprogramming-allthesewillbediscussedinmoredetailinChapter4.Althoughinvestmentsinlargerwaterandsanitationinfrastructurewillrequireresourcesoutsidetheremitofnutrition,theframeworksandcomponentsofsucheffortsarebrieflydescribedtofacilitateadvocacyandplanningofco-sitingWASHeffortsinnutritionallyvulnerableareas.Finally,WASHprogrammesshouldhaveagreaterandmoresustainableimpactwhentheycombinethreefollowingelements:accesstogoodqualityhardwareandservices,demandcreation–servicesuptakeandanenablinginstitutionalandpolicyenvironment.34

32-ACF(2012)“TheEssential:nutritionandhealth”33-UKAid(2013)“Water,sanitationandhygieneevidencepaper”34-WHO/UNICEF/USAID(2015)“Improvingnutritionoutcomeswithbetterwater,sanitationandhygiene”


tAble 3: NON-ExHAUSTIVEExAMPLEOFWASHINTERVENTIONS

WAter suPPlY AnD WAter QuAntitY

Watersafetyplanning

Constructingorimprovingwatersupplysystemsandservices

Providingsafeandreliablepipedwatertouser’shome

Constructingand/orrehabilitatingpublicwaterpoints,boreholes,protecteddugwells,etc.

Emergencywatersupplyby,forexample,watertrucking

WAter QuAlitY

Useofprovenwatertreatmentmethods,suchasfiltration,boilingorsolar.Chlorinecanbeusedbutisineffectiveagainstprotozoaandinturbidwater35

Protectionfrom(re)contaminationthrough,forexample,pipeddistributionandsafestorageincleancoveredcontainers

sAnitAtion

Providingaccesstohygienicsanitationfacilitiesthatsafelyremoveandtreatfeces

Sanitationsafetyplanning

Community-LedTotalSanitation,School-LedTotalSanitationandSanitationMarketing

Constructingfacilitiesappropriateforinfantsandtoddlers

Enablingaccessanduseoflatrinesforthosewithphysicallimitations

hYgiene Promotion

AnD eDucAtion

Educationonhandwashingwithsoap(orashifsoapisnotavailable)andwateratcriticaltimes

Promotingsafefoodhygienepractices

Behaviourchangeprogrammingaddressingthekeybehaviouraldeterminantsforthetargetpopulation(goingbeyondeducation)

environmentAl sAnitAtion

Improvingenvironmentalhygienepracticese.g.keepinganimalsawayfromtheareaswherefoodisprepared,childplayareasandwaterresources

Improvingsolidwastedisposalandmanagement

Controldiseasevectorssuchasflies,mosquitoes,cockroachesandratsbycoveringfood,improvingdrainageandsafelydisposingofgarbageandnon-reusablematerialsintoawastereceptacleorprotectedpits

WAter AnD sAnitAtion

governAnce

Advocacyonequitableaccesstowaterandsanitation

Supportinglocal/nationalauthoritiesinestablishingsustainablepricingpolicy

Communitymobilizationandimplementationofconflictmanagementmechanismsamongwaterusers,etc.

Adapted from: WHO (2010) “Nutrition Landscape Information System”

ACFbookonwater,sanitationandhygieneforpopulationsatrisk:http://www.actionagainsthunger.org/sites/default/files/publications/Water_sanitation_and_hygiene_for_populations_at_risk_12.2005.pdf

GlobalWASHClustertoolsandresourcescanbefoundhere:http://washcluster.net/tools-and-resources/

WHOguidelinesforwaterandsanitation:http://www.who.int/water_sanitation_health/en/

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35-ListofProductsthathavebeenfoundtomeetoneofthethreeWHOrecommendedperformancelevels: http://www.who.int/household_water/scheme/products/en/

27WAsh’nutrition


6. globAl trends in undernutrition And WAsh

In2015,anestimated156millionchildrenunderfivewerestunted,50millionwerewastedandaround17millionsufferedfromsevereacutemalnutrition,mostofthemlivinginSouthEastAsiaandSub-SaharanAfrica.36Sofar,globaleffortstofightundernutritionandmakeprogress towards thefirstMillenniumDevelopmentGoal (MDG),whichaims to “eradicate extreme poverty and hunger”,byhalvingtheproportionofpeoplesufferingfromhunger,haveachievedsomesuccess.Thus,theproportionofundernourishedpeopleinthedevelopingregionshasfallenbyalmosthalfsince1990,from23.3%in1990–1992to12.9%in2014–2016.37Stuntingrateshavealsodecreased;however,globalwastingprevalenceamongchildrenunderfivehasremainedstableandbillionsofpeoplestillsufferfromvitaminandmineraldeficiencies.38

Figure 6: GLOBALTRENDSINCHILDSTUNTINGANDWASTING

Stunting

Wasting

In 2014, the global wasting rate was 7.5 per cent.

Between 1990 and 2014, stunting prevalence declined from 39.6 per cent to 23.8 per cent...

Nearly a third of all wasted children were severely wasted, with a global prevalence in 2014 of 2.4 per cent.

Approximately 1 out of every 13 children in the world was wasted in 2014.

1990

2014

2014

…and numbers affected declined from 255 million to 159 million.

Globally, 50 million children under 5 were wasted, of which 16 million were severely wasted in 2014.

The global trend in stunting prevalence and numbers of children affected is decreasing...

- 96M

50M

Source: UNICEF/WHO/World Bank Group (2015) “Levels and trends in child malnutrition”

Despite the substantial headway that has been made, undernutrition remains the largest simple contributor to diseaseworldwideandnutrition-relatedfactorsaccountedfor3.1 million child deaths in 2014.39Safeandsufficientdrinkingwater,alongwithadequatesanitationandhygienehavehadimplicationsacrossallMillenniumDevelopmentGoals(MDGs)–fromeradicatingpovertyandhunger,reducingchildmortality,improvingmaternalhealth,combatinginfectiousdiseases,increasingschoolattendance,toensuringenvironmentalsustainability.40Muchprogresshasbeenachievedoverthepastdecade:2.6billionpeople have gained access to an improveddrinkingwater source and2.1billionpeople have gained access to animprovedsanitationfacilitysince1990.41Theproportionofpeoplepracticingopendefecationgloballyhasfallenbyalmosthalf.Thenumberofchildrendyingfromdiarrhealdiseases,whicharestronglyassociatedwithpoorwateraccess,inadequatesanitationandhygiene,hassteadilyfallenoverthetwolastdecadesfromapproximately1.5milliondeathsin1990to0,5millionin2015.42

Despiteprogress,theMDGtargettohalvetheproportionofthepopulationwithoutaccesstoimprovedsanitationfacilitieswasmissedbyalmost700millionpeople;946millionstilldefecateintheopen.43Billionslacksafewaterthatisreliablyandcontinuouslydelivered in sufficientquantities.44Asvital andbasicas it is, adequateaccess toWASHservices remainsanimmensechallengeforbillionsofpeople,puttingthem,especiallychildren,atgreatriskofacquiringpreventablewater-bornediseases,undernutritionandprematuredeath.

36-UNICEF/WHO/WorldBankGroup(2015)“Levelsandtrendsinchildmalnutrition” 37-TheMillenniumDevelopmentGoalsReport(2015)38-UNICEF/WHO/WorldBankGroup(2015)“Levelsandtrendsinchildmalnutrition”39-WHO(2015)40-UNWater/WHO(2014)“GlobalAnalysisandAssessmentofSanitationandDrinking-Water:GLASSReport2014”41-JMP(2015)“KeyFactsfromJMP2015Report”42-WHO(2014&2015)“Preventingdiarrheathroughbetterwater,sanitationandhygiene:exposureandimpactsinlow-andmiddleincomecountries”43-JMP(2015)“KeyFactsfromJMP2015Report”44-WHO(2014)


mAP 1: DIARRHEADEATHSUNDER5

Source: WHO (2015)

mAP 2: WASTINGCHILDRENBYREGION

Source: UNICEF (2016)

mAP 3: PERCENTAGEOFCHILDRENUNDER5WHOARESTUNTED

Source: WHO (2010-2016)

29WAsh’nutrition


Today, the world’s attention is turning to the implementation of the 2030 Agenda for Sustainable Development(http://www.un.org/sustainabledevelopment/development-agenda/).Muchremainstobedonetoendextremepoverty,tackleclimate change and reduce inequalities and injustice across populations. Sustainable development cannot be realizedwithoutnutritionalwell-beingandreachingthe2025GlobalNutritionTargetssetbytheWorldHealthAssembly.Moreover,achieving important global health goals, such as ending preventable child and maternal deaths, will likewise requireaddressingundernutritioninallitsforms.45IntegratingWASHinterventionsintonutritionactions,strategiesandbudgetswillbefundamentalforreachinghealthandnutritiongoals.ThebeginningofaneweraofSustainableDevelopmentGoals(SDGs),whichhighlightjoint multi-sector action, collaboration and engagement, seemstobetherighttimetodemonstrate,practically,hownutritionandWASHactionscanbeintegrated,forbetterhealthandthebettermentofhumanity.46

LinkingGoal2(ZeroHunger),Goal3(GoodHealthandWell-Being)andGoal6(CleanWaterandSanitation)willdefinitivelyimpactonHealthandNutritionoutcomes.

Undernutritionwasresponsiblefor3.1 million child deaths in 2014 (Who, 2015).Ithasseriousconsequencesonindividualhealthanddevelopmentalongwithunderminingeconomicgrowthandperpetuatingpoverty.Allthisisunnecessaryascauses of undernutrition are totally preventable.

Factors and pathways leading to undernutrition are diverse, complex and most often interconnected.Keybroadfactorsthatinfluencenutritionalstatusarefood,caringpracticesandaccesstohealthcare/healthyenvironment.Allofthemarelinkedtowater,sanitationandhygiene.

the first 1,000 daysbetweenawoman’spregnancyandherchild’s2ndbirthdayofferauniquewindowofopportunitytobuildhealthierandmoreprosperousfutures.Thedamagethathappensduringthisperiodisusuallyirreparable.

Multidimensional nature and causes of undernutrition call for coherent and coordinated responses that transcend traditional sector boundaries.

nutritional security refers to a long-term, sustainable and at-scale impact on the nutritionalstatusofpopulationsandamulti-sectoralapproachisneededtoachieveit.

Undernutritionand lackof access to safewater, sanitationandhygiene remainmajor globalchallenges.to reach the new Sustainable development GoalsandglobaltargetsfornutritionandWASH,integration will be the key component.

KeYMessaGes

Chapter 1

45-WHO/UNICEF/USAID(2015)“Improvingnutritionoutcomeswithbetterwater,sanitationandhygiene”46-Ibid


Jova

na D

odos

© A

cF –

sen

egal

, 201

5

2linking

nutritionAl outcomes with the

WAsh environment

1. nutritionAl stAtus And the WAsh environment relAtionship

2. keY pAthWAYs to undernutrition

3. contributing WAsh-relAted diseAses

4. WAsh interventions effects on heAlth

31WAsh’nutrition


lin

kin

g n

utr

itio

nA

l o

utc

om

es w

ith

th

e W

Ash

en

vir

on

men

t


CHILDRENUNDER5MORTALITYWAS5.9 million IN 2015.

Wash related diseases accounted for 27%.

around 45% of child deathsWEREATTRIBUTABLETOUNDERNUTRITION.

under 5 mortAlitY in 2015 (WHO, 2016)

13%pneumoniA

6%injuries

5%mAlAriA

1%meAsles

9% diArrheA

2%premAturitY

1%hiv/Aids

10%other group 1 conditions

8% congenitAl AnomAlies And other non-communicAble

diseAses

1-59months

neAonAtAlmortAlitY0-27 dAYs

27%45%

45% of deAth Are

AttributAble to undernutrition

33WAsh’nutrition


1. nutritionAl stAtus And the WAsh environment relAtionship

Inthepastdecadedeathsduetoinfectiousdiseases,suchasdiarrheaandmalaria,oftenrelatedtopoorwater,sanitationandwastemanagement,havedeclined.47Nevertheless,poorWASHconditionsremainassociatedwithasignificantproportionofdeaths(bothneonatalandpostneonatal)anddiseasesamongchildrenunderfive.Mostofthisburdenfallsonchildreninlow-and-middleincomecountries.48Chapter2providesanoverviewoftheexistingevidence-basedknowledgeoflinkingnutritionaloutcomeswiththeWASHenvironmentandexplainshowWASHinterventions,bypreventinginfectionanddisease,helpreduceundernutrition.

Thethreemainunderlyingcausesofundernutrition,namelyunsuitableor insufficientfoodintake,poorcarepracticesanddisease,aredirectlyorindirectlyrelatedtoinadequateaccesstowater,sanitationandhygiene.49

Figure7illustratesmultiplepathways,bothdirect and indirect,whichdemonstratethedependenceofnutritionalstatusontheWASHenvironment.PoorWASHconditionsfacilitateingestionoffecalpathogenswhichleadstodiarrhea,intestinalwormsandenvironmentalentericdysfunction.Thisdirectlyrelatestothebody’sabilitytoresistandrespondtosicknessbyaffecting the absorption of nutrients and decreasing body’s immunity.50Otherwaterandsanitation-relatedillnessessuchasmalaria,dengue,leishmaniosis,trypanosomiasis,yellowfever,togetherwithchronicpoisoningduetopoorchemicalqualityofwateralsocontributetothedeteriorationofnutritionalstatus.51

Figure 7: RELATIONSHIPBETWEENPOORWASHANDCHILDUNDERNUTRITION

Source: Dangour at.al (2013), adapted by Lapegue J., ACF (2014) “WASH and nutrition factsheet”

47-WHO(2016)“Preventingdiseasethroughhealthyenvironments:aglobalassessmentoftheburdenofdiseasefromenvironmentalrisks”48-WHO(2014)“Mortalityandburdenofdiseasefromwaterandsanitation”49-ACF(2011)“Water,SanitationandHygienePolicy”50-Dangouretal(2013)“Interventionstoimprovewaterqualityandsupply,sanitationandhygienepractices,andtheireffectsonthenutritionstatusofchildren(Review)”51-ACF(2011)“Water,SanitationandHygienePolicy”


indirect links between WASh and nutritional status, referringprimarilytoabroadersocio-economicenvironment(accessandaffordabilityofwater,sanitationandhygieneservices,distancefromhouseholdtoawaterpoint,educationandpoverty)

shouldalsobetakenintoconsideration.Forexample,a lackofsafewaterclosetothehomehasmanyindirecteffectson

nutrition.Peopleareoftenleftwithnochoicebuttodrinkunsafewaterfromunprotectedsources.Twothirdsoftheburden

ofwater-fetchingandcarryingwaterhomefallsonwomenandyoungchildren.52Timewastedonwatercollectiontranslates

intodecreasedproductivity, lowerschoolattendanceand lesstimeforcaring forchildrenandthehousehold.53Note that

inadequatechildcareisoneoftheunderlyingcausesofundernutrition.Alongsimilarlines,inadequateaccesstowaterand

sanitationimpactstheeducationalsuccessofschool-agechildren,resultinginareducedopportunitytowork,perpetuated

povertyandunderminedhouseholdfoodsecurity–theunderlyingcausesofmaternalandchildundernutrition.54

2. keY pAthWAYs to undernutrition

InadequateWASHconditionsfacilitateingestionoffecalpathogenswhichleadstodiarrhea,intestinalwormsandenvironmental

entericdysfunction,thethreekeypathwaysfrompoorWASHtoundernutrition.

2.1. dIaRRHea

Diarrheamostoftenresultsfromtheingestionofpathogensfromfecesthathavenotbeenproperlydisposedofandfromthe

lackofhygiene.Apersonisclassifiedashavingdiarrheawhensheorheexperiencesmorethanthreeliquidstoolsperday.55

Diarrhearemainsa leading cause of mortality among children under five in the world,andoneofthebiggestkillersofthisagegroup in thesub-SaharanAfrica.56 In2015, inadequateWASHconditionsaccounted for531,000diarrhealdeathsamong

childrenunderfive,ornearly1,450childdeathsperday.57

Existingevidenceshowsthat50%ofundernourishment isassociatedwithrecurrentonsetsofdiarrhea.58Undernourished

childrenaremoresusceptibletorepeatedboutsofentericinfectionsand,hence,areatgreaterriskofdyingfromdiarrheaand

otherdiseases,includingrespiratoryinfections.The probability of dying from diarrheal disease among children under five is 10 times higher if the child is affected by severe acute malnutrition.59Frequentillnesses,inreturn,causepoornutritionalintakeandreducednutrientabsorption.Childrenarethuslockedinto“a vicious circle” ofrecurringsicknessandfurtherdeteriorationoftheirnutritionalstatus(Figure9).60

Diarrheaalsohasanimpactonstunting.Currentevidenceshowthat“with each diarrheal episode and with each day of diarrhea

before 24 months” theriskofstuntingincreases.Theproportionofstuntingattributabletofiveormoreepisodesofdiarrhea

beforetheageof2is25%.61

52-UKAid(2013)“Water,sanitationandhygieneevidencepaper”53-Ibid54-ACF(2011)“Water,SanitationandHygienePolicy”55-WHO(2011)“Water,sanitationandhygieneinterventionsandthepreventionofdiarrhea”56-WalkerCetal(2013)“Globalburdenofchildhoodpneumoniaanddiarrhea”57-WHO(2016)58-WalkerCetal(2013)“Globalburdenofchildhoodpneumoniaanddiarrhea”59-Blacketal(2008)“Maternalandchildundernutrition:globalandregionalexposuresandhealthconsequences”60-UNICEF(2013)“ImprovingChildNutrition:TheAchievableImperativeforGlobalProgress”61-Walkeretal 2013

35WAsh’nutrition


Figure 8: MEDIANAGE-SPECIFICINCIDENCESFORDIARRHEALEPISODESPERCHILDPERYEARFROMTHREEREVIEWSOFPROSPECTIVESTUDIESINDEVELOPINGAREAS

0

1

2

3

4

5

6

0-5m 6-11m 1year 2years 3years 4yearsAge grouP

● 1955-1979● 1980-1990● 1990-2000

no.

of e

piso

des

per p

erso

n pe

r yea

r

Source: The global burden of diarrheal disease, WHO 2003

Figure 9: VICIOUSCYCLEBETWEENINTESTINALINFECTIONSANDUNDERNUTRITION

RESPIRATORYINFECTIONS

ImpairedimmunefunctionImpairedbarrierprotection

Inadequatewater,sanitationandhygiene Diarrheaandotherintestinalinfections

Undernutrition

hiV/aids

CatabolismMalabsorption

NutrientsequestrationDecreasedietaryintake

Source: Pathways linking WASH with nutrition (WHO, 2007), Brown 2003, adapted ACF

2.2. NeMaTOdes

Caused by different species of parasitic worms, the infection istransmittedbyeggspresent inhumanfeces,whichinturncontaminatesoil inareaswheresanitation ispoor. Infectioncanbecaughteasilybywalkingbarefootonthecontaminatedsoiloreatingcontaminatedfood.Nematode infections interfere with nutrient uptake in children, whichcan lead to anemia,malnourishment and impairedmental andphysicaldevelopment.Theyposeaseriousthreattochildren’shealth,education,and productivity.62 Parasitic, intestinal worms, such as schistosomes(contractedthroughbathingin,ordrinkingcontaminatedwater)andsoil-transmittedhelminths(contractedthroughsoilcontaminatedwithfeces)causebloodlossandreducedappetite,bothofwhichnegativelyaffectachild’snutritionalstatus.63

62-DewormtheWorld(2014)63-GenerationNutrition(2015)“Theroleofwater,sanitationandhygieneinfightagainstchildundernutrition”

In developing countries every second,

pregnant women and about 40% of preschool

children are estimated to be anemic.

Maternal anemia increases risks of poor

outcomes during pregnancy and childbirth,

risk of morbidity in children and reduced

work productivity in adults. Iron-deficiency anemia (IDA) is aggravated by hookworm infections, malaria and other infectious diseases contracted through a poor WASH

environment (WHO, 2015).

no

te


2.3. eNvIRONMeNTal eNTeRIC dYsfuNCTION (eed)

Definedasa“chronic infection of the small intestine caused by extended exposure to fecal pathogens”,64environmentalentericdysfunction(EED)reduceschildren’sabilitytoabsorbnutrientsandsubsequentlyprovokeundernutritionandgrowthstunting.Theingestionofmicroorganisms,notalwayspathogenic,hasbeensuggestedtobethemaincauseofEEDinchildrenunder2yearsold.EstablishmentofEEDearly in life,duringinfancy, isgreatlyfacilitatedbyunhygienicenvironmentsinwhichinfantsandyoungchildrenliveandgrow.65Oncecontracted,EEDcausesabnormalchangesinthestructureandfunctionofthesmallintestine.Itflattensvilliandprovokesalossofvillitightjunctionmakingitharderforfoodandeasierfordiseasetogetin(Figure10).IthasbeenhypothesizedthatEEDmaybetheprimarycausalpathwayfrompoorsanitationtostuntingaswellasplayingaroleinthereducedefficacyoforally-administeredvaccinessuchaspolioandrotavirus.66AssociatedwithpoorWASHenvironmentandusuallyasymptomatic,EEDmayhelpexplainwhypurelynutritionalinterventionshavefailedtoreduceundernutritioninmanycontextsoverthelongterm.67

Figure 10: DIFFERENCEBETWEENHEALTHY(LEFT)ANDEED-INFECTEDINTESTINE(RIGHT)

Source: Web

64-Humphrey(2009)“Childundernutrition,tropicalenteropathy,toilets,andhandwashing”.65-Humphrey(2015)“Preventingenvironmentalentericdysfunctionthroughimprovedwater,sanitationandhygiene:anopportunityforstuntingreductionindevelopingcountries”.66-CMAMForum(2014)“EnvironmentalEntericDysfunction-anOverview”.67-Beryetal(2015)“Horizontalchallenges:WASHandNutritionintegration.

37WAsh’nutrition


3. contributing WAsh-relAted diseAses

BesidesFaecallyTransmittedInfectionssuchasdiarrhea,intestinalparasiteinfectionsandEED,thereareotherWASH-relateddiseasesknowntobeassociatedwithdecreasedimmunityandundernutrition.

Evidenceshowsthatmalariaisassociatedwithvariousnutrientdeficienciesaswellasunderweightstatusinchildrenunderfive.Largenumbersofchildrensufferanddiefrommalariaduetolackofproteinenergy,zinc,vitaminAandothermicronutrients.Comparablytodiarrhea,malariaandundernutritionformaviciouscircleofdiseaseandfurtherdeteriorationofnutritionalstatus.68An inadequateWASHenvironment,suchasstandingwatercausedbypoordrainageanduncoveredwatertanks,facilitatesthecreationofmosquitobreedingsitesandthespreadofmalaria.

Alongsimilarlines, acute respiratory infections (Ari),aggravatedbypoorhygienepractices,leadtothelossofbodyweight.MalnourishedchildrenwithsevereARI,suchaspneumonia,haveahighermortalityriskthanhealthychildren.69Inaddition,it has been demonstrated thatARIs prevent improvement of vitaminA status in young infants leading to micronutrientdeficiency.70ApoorWASHenvironmentfacilitatesthespreadandtransmissionofneglected tropical diseases (ntds),suchastrachoma,dengue,chikungunya,etc.,whicharetheunderlyingcausesofstunting,wastingandmicronutrientdeficiencies.Atthesametime,poornutritionincreasessusceptibilitytoNTDinfection.ThecombinationofNTDinfectionsandundernutritionperpetuatesacycleofdisease,undernutritionandpoverty.71

68-Erdhartet.al.,2006.69-Rodrigezetal,2011.70-RahmanMetal.(2016)“AcuteRespiratoryInfectionsPreventImprovementofVitaminAStatusinYoungInfantsSupplementedwithVitaminA”71-GlobalNetworkonNeglectedTropicaldiseases(2015)“Hunger,NutritionandNTDs”.

©A.Parsons/i-ImagesforActionAgainstHunger


4. WAsh interventions effects on heAlth

During past decades, numerous publications and studies have reported that improvements in drinkingwater, sanitationfacilities andhygienepracticeshavepositiveeffectsondisease reduction,particularly in lessdevelopedcountries.Whencarriedouteffectively,WASHinterventionshavethepotentialtointerrupttransmissionofpathogens,reducediseaseburdenandbringsignificanthealthandnon-healthbenefits.

Figure 11: REDUCTIONINDIARRHEALMORBIDITY-(%perinterventiontype)

44%hAnd WAshing

With soAp

39%point-of-use

WAter treAtment

32%sAnitAtion

28%hYgiene

educAtion

25%WAter supplY

11%source WAter

treAtment

Source: Fewtrell et al. (2005)

Sanitation, coupledwith good hygiene, acts as a fundamental ‘primary barrier’ to isolate fecal matter from the generalenvironment.However,oncefecalmatterisintheenvironment,itcaneasilybespreaddirectlytohosts,andindirectlytofood,throughfingers,flies,fluids,andinfieldsorfloors.Therefore,‘secondary barriers’areneededtoprotectthepublicexposedtosuchcontamination.Goodhygienepractices,particularlyhandwashingwithsoap,serveasvitalsecondarybarrierstothespreadofdiarrheal,respiratoryandpossiblyotherinfectiousdiseasesastheypreventpathogensfromreachingthedomesticenvironmentandfood,andtheirsubsequentingestion(Figure12).72

72-WorldBankGroup(2015)“SanitationandHygiene:Whytheymatter?”.

©A.Parsons/i-ImagesforActionAgainstHunger

39WAsh’nutrition


Figure 12: THEF-DIAGRAM-Fecal-oralroutesofdiseasestransmissionandhowWASHcanpreventit.

Source: Perez at al. (2012), adapted from Wagner and Langlois (1958)

Understandingfecal-oraldiseasestransmissionroutesisessential.ImplementingindividualormultipleWASHinterventionsdependsonwhethereach transmission pathway(fluids,fingers,flies,etc.)aloneissufficienttomaintainfecal-oraldiseaseinthepopulation.Ifthatisthecase,single-pathwayinterventionswillhaveminimalbenefit.Thisisespeciallytrueforemergenciesandepidemics,whereenvironmentalconditionsfavourthespreadofcommunicablediseases.Inthisinstance,watersupplyand/orwaterquality improvementsmayhaveminimal impact ifnotaccompaniedwith improvedexcretamanagementandadequatehygienebehaviour.73 It is alsoworthmentioning thatdiarrheaspreadsbyvarious interactivepathwaysand thatWASHinterventionsneedtobewellharmonizedandprovidehighcoverageinordertobeeffective.74

ThereisstrongevidenceofthepositiveimpactofWASHinterventionsondiarrheal morbidity,especiallyamongchildrenunderfive.75AsseeninFigure13,thegreatestreductionsindiarrheadiseaserisk(upto73%)canbeachievedthroughservicesthatprovideasafeandcontinuouspipedwater supply and through sewerage connections that remove excretafrom both households and community environments.76 In addition, ameta-analysisofhandwashingstudiesconductedindevelopingcountriesconcludedthathandwashingwithsoapcanreducetheriskofdiarrheaupto48%.77

73-ParkinsonJ(2009)“ReviewoftheEvidenceBaseforWASHinterventionsinEmergencyResponses”74-UKAid(2013)“Water,SanitationandHygieneevidencepaper”75-Fewtrelletal.,200576-WHO(2014)”Preventingdiarrheathroughbetterwater,sanitationandhygiene:exposuresandimpactsinlow-andmiddle-incomecountries” 77-Brownetal.,2011

Nutrition and WASH integration implies focusing more on the “field” transmission route which usually receives less attention than other transmission routes as it concerns mainly young children (e.g. crawling among the animals and putting stuff in the mouth). This suggests considering a new range of WASH prevention measures (see “Baby WASH” concept, Chapter 4).

no

te


Figure 13: EFFECTOFIMPROVEMENTSINDRINKINGWATERANDSANITATIONONDIARRHEADISEASERISK

23%

11%

45%

38%

28%

14%

73%

PiPeD WAter, sYstemAticAllY

mAnAgeD

WAter eFFicientlY treAteD AnD sAFelY

storeD in the householD

imProveD Point source oF DrinKing-WAter

bAsic PiPeD WAter on Premises

unimProveD source oF DrinKing-WAter

LOW

HIGH

ris

k t

o h

eAth

LOW

HIGH

ris

k t

o h

eAth

69%

16%

63%

communitY sAnittAion or seWer connections

imProveD sAnitAtion Without seWer

connections

grouPeD: imProveD SAnitAtion (incLudinG SeWer connectionS)

unimProveD sAnitAtion FAcilities

28%

Source: WHO, 2014

Currentresearchalsoconfirmsthatwater,sanitationandhygiene interventionsprevent intestinal parasitic infections andotherdiseasesassociatedwithpoornutritionalstatus.78Forexample,accesstoanduseoffacilitiesforthesafedisposalofhumanexcretahavebeenshowntoreducetheriskofsoil-transmittednematodeinfectionsby34%anduseoftreatedwaterby54%.79Childrenunderfiveinhouseholdsthatreceivedplainsoapandhandwashingpromotionhada50%lowerincidenceofpneumoniathanincontrolgroups.80Approximately42%oftheglobalmalariaburdencouldbepreventedbyenvironmentalmanagement,includingremovingstagnantorslowlymovingfreshwateranddrainage.81

the etiology of eed remainsunclear.Nutritionaldeficiencies, specially zincandvitaminAdeficiencies, imbalancesofgutmicrobiome,Helicobacterpiloripresenceandbacterialovergrowth,mycotoxinsorHIVinfection,seemstocontributetothemulticausalityofEED.EEDhasbeenassociatedwithlineargrowthfalteringinseveralstudiesanditiscurrentlyproposedastheprimarycausalpathwayfrompoorsanitationandhygienetostunting,ratherthandiarrheaorsoil-transmittedhelminths.82

78-Pruss-UstunAetal(2008)“Theimpactoftheenvironmentonhealthbycountry:ameta-synthesis”79-Strunzetal,201480-Luby,200581-WHO(2016)“Preventingdiseasethroughhealthyenvironments:aglobalassessmentoftheburdenofdiseasefromenvironmentalrisks”82 - Baby wash and the 1000 days, a practical package for stunting reduction, ACF-Spain, 2017

41WAsh’nutrition


Despitenotabledeclineininfectiousdiseases,poor WASh conditions remain associated with a significant proportion of deaths(bothneonatalandpostneonatal)anddiseaseamongchildrenunderfive.

The three main underlying causes of undernutrition, namely unsuitable or insufficient foodintake,poorcarepracticesanddisease,aredirectly or indirectly related to inadequate access to water, sanitation and hygiene.

InadequateWASH conditions facilitate ingestion of fecal pathogenswhich leads to diarrhea, intestinal worms and environmental enteric dysfunction, the three key pathways from poorWASHtoundernutrition.

50% of undernourishment is associated with recurrent onsets of diarrhea. Frequent illnessimpairsnutritionalstatusandpoornutritionincreasestheriskofinfection.Thisformsa“vicious circle”ofrecurringsicknessandfurtherdeteriorationofnutritionalstatus.

Other WASH-related diseases such as malaria, acute respiratory infections and neglected tropical diseases such trachoma, dengue, chikungunya are known to be associated with decreased immunity and undernutrition.

Improvementsindrinkingwater,sanitationfacilitiesandhygienepracticeshavepositiveeffectson disease reduction.WASh interventions have the potential to interrupt transmission of pathogens, reduce disease burden and bring significant health and non-health benefits.

Beyondtheimpactondiseasereduction,agrowingbaseofevidenceindicatesthattheWAsh environment can be critical in shaping children’s nutritional outcomes. ThisisespeciallytruefortheeffectsofWASHconditionsonstunting,whiletheimpactsonwastingarestilltobeexplored.

the evidence is sufficient to justify and support the integration of nutrition and WASh interventions.

KeYMessaGes

Chapter 2


© A

cF –

Pak

ista

n, 2

015

3WAsh’nutrition

strAtegY

1. Aligning WAsh And nutrition progrAmming

2. integrAtion

3. focus on the mother And child dYAd

4. emphAsis on behAviour chAnge

5. coordinAtion of stAkeholders

6. ensuring A WAsh minimum pAckAge

43WAsh’nutrition


WA

sh’n

utr

itio

n s

trA

teg

Y


become A WAsh’nutritionolYmpic chAmpion!

mAinlY development conteXts, but not onlY...

mAinlY emergencY conteXts, but not onlY...

integrAtion

PILLAR 1

mother And child dYAd

PILLAR 2

behAviour chAnge

PILLAR 3

coordinAtion

PILLA

R 4 minimum pAckAge

PILLAR 5

45WAsh’nutrition


1. Aligning WAsh And nutrition progrAmming

“WASH’ Nutrition” refers to any type of intervention aiming at complementing the prevention (before the incidence ofundernutrition)andthetreatmentofundernutrition(MAMandSAM)throughthestrengtheningofaccesstowater,sanitationandhygieneservices.Aligningimplies(re)definingthestrategicorientationsofWASHandnutritionprogrammesandidentifyingprogrammaticopportunitiesbasedon:

context-specificneedsandpriorities; accessandsecurity; themandateandcapacitiesoftheorganization/mission; identified areas of common interest (e.g. 1,000-day window ofopportunity);

presenceandcapacitiesofotherstakeholdersalreadypositionedintermsofWASHandnutritionintegration;

nationallaws,policiesandstrategiesonWASHandnutrition; specificstrategicpositioningofkeydonors.

there are different options for aligning WASh and nutrition:

1 Bybuildinganintegratedstrategy,producedinacollaborativewayandbasedonajointinter-sectoralanalysis,planningandstrategicthinking. The example in this regard is Acf nutrition Security Policy,83 an overarching long-term positioning that encompassesbothpreventiveandreactiveinterventionsinthenutrition,WASH,mentalhealthandcarepractices,foodsecurityandhealthnexus;

2 Byensuringthatastrategyforonesector includes importantcross-cuttingissuesandspecificobjectivesofanothersectorandidentifiesopportunities for integration. ItmeansaproactiveapproachwithallWASH,MHCP,health,nutritionandfoodsecuritypartnerstoensureintegrationofnutritionobjectivesinallWASHprojectsfromtheoutset.

there are 5 main pillars of the WASh’nutrition strategy initially designed by West and central Africa WASh regional Group in 2012 with the support of many partners. this strategy was adapted in 201584:

1 ensuring good geographical concentration of WASh projects in the areas affected by undernutrition, primarily in the areas with a high prevalence of GAM.

2 Focusing on the “mother/caretaker – malnourished child”dyadandfollowingthemfromnutritioncentrestohomesoastopreventtheviciouscircleof“diarrhea/nematodeinfections/EED–undernutrition”andassociateddiseases.

3 placing emphasis on behaviour change,knowingthatprovisionofhardwareonly(accesstowaterandsanitationfacilities)bringslittlebenefittohealthifitisnotaccompaniedwithsuitablehygienebehaviour.

4 improving coordination and enhancing partnership among relevantministries (nutrition, health, food security,waterresourcesandsanitation),humanitarianorganizationsandotherrelevantstakeholderssoastoensuretheintegrationofhealthandnutritiongoalsinallWASHprojectsfromthestart.

5 ensuring and reinforcing the principle of WASh minimum package (thiswillbediscussedinmoredetail later inthisChapter)bothinhealthandnutritioncentresaswellasinthehouseholds/communitiesaffectedbyundernutrition.

boX 3: WASH’NUTRITIONTARGETING

WASH’Nutritionstrategywasinitiallydesignedtothetargetingofchildrenunderfiveandofparticularinterestinhumanitariancontextswithacuteundernutrition.Thiswasespecially true forpillar4oncoordinationandpillar5onWASHminimumpackage.However,themethodologicalapproachesofthestrategy,thefivepillars,canalsocoverothertypesofundernutritionandbeadaptedtodevelopmentcontextswherebothundernutritionratesandWASHconditionsareofconcern.

83-ACF(2014)“NutritionSecurityPolicy”84-WestandCentralAfricaRegionalWASHGroup(2015)“WASHinNut”StrategyforSahel

There is no single model that can be applied

to all settings or “one size fit all” solution.

The process of developing strategy is as the

document itself. If the strategy is developed

in a participatory and inclusive way, involving

both sectors in the planning process, it is far

more likely that integrated programmes will

be implemented. Understanding the purpose

and benefits of incorporating different WASH

components into nutrition programmes and

vice versa, helps clarify and align goals across

sectors.

no

te

Integrating WASH and Nutrition should be seen as a “two-way street”. Both sectors have a role to play in ensuring that issues/objectives of one sector are properly taken into account by another.

no

te


2. integrAtion

Better alignment allows WASH and nutrition programmes to maximize their impact, increase cost-effectiveness andsustainability,andcreategreaterbenefitsforthebeneficiaries.

TherearemanywaysinwhichWASHandnutritionprogrammescouldintegrate.Thelevelofintegrationshouldbedecidedonthebasisofsectorcapacitiesandcontext-specificconditions.Evenwhenstrongsynergiesarenotpossible,dueto,forexample,fundingconstraintsoractivitytimetablespreventingdifferentsectorsfromoperatingasasingleprogramme,therearestilloptionsforaligninginterventionsaslongasthereisagoodcoordination,communication and collaboration between sectors. Figures 14 illustratesdifferent levelsandtypesof integrationthatmaybeappropriate indifferentcircumstances.

Fromtheoperationalpointofview,WASHandnutritionsectorsworkinsynergywhen: Thereisjoint situation analysis and planning; Thereareunifiedand integrated programme componentsaimingatpreventing/reducingundernutrition:oneormore

indicatorsincorporatedintotheprojectobjectivesofanothersectorand/orthereisacommon specific objectiveforbothsectors;

Thereisajoint,synchronizeddeliveryofinterventionsinthesame geographical area, targeting the same beneficiaries (individuals,households,communities);

Thereisregular and significant communicationbetweenWASHandNutritionactors,awell-coordinatedmanagementandreportingstructure;

Thereisjointmonitoring and evaluationofimplementedactivities.

Figure 14:INCREASINGLEVELSOFMULTI-SECTORALINTEGRATION

coherenceensuringconsistencyandminimizingduplicationofinterventions,policiesandstrategies;inotherwords,makingsurethatoneinterventiondoesnotworkagainstanotherandhavecounterproductiveeffectsonundernutrition.

Alignment/mAinstreAming nutritionensuringthatdifferentinterventionstakeintoaccountnutritionalissues,arealignedonacommonnutritionalgoalandprioritizeactivitiesthathavethehighestpotentialtocontributetoachievingthisgoal.

comPlementAritYensuringthatinterventionsaredesignedtocomplementeachotherinordertoactonthedifferentdeterminantsofundernutrition,usingeachintervention’saddedvalue.

sYnergYoccurswhenthecombinedeffectofinterventionsissignificantlygreaterthanthesumoftheeffectsoftheirseparateparts.Interventionsaredesignednotonlytocompleteeachother,butalsotointeractamongstthemselvestomaximizetheirnutritionalimpact.

Source: ACF (2014) “Nutrition Security Policy

2.1. GeOGRaPHICal CO-sITING Of wasH aCTIvITIes IN NuTRITIONallY vulNeRable aReas

Theuseofrelativelylow-costandeasy-to-applymappingtechniquestooverlayvariouskeyindicatorstobetterunderstandthe relationship betweenWASH conditions and undernutrition rates can help improve decision-making for interventionsandprogramming.85Thisapproachcanbeusedatanygeographicallevel(household,community,district,region,etc.)asan

85-RamosM.andKendleA.,ECHOAmmanandSavetheChildren(2014)“Integratedprogramming:MappingofnutritionandWASH”

pillAr1

Thisguidebookdefines integrationasawayofworkinginwhichWASHandnutritionsectorsoperateinsynergy.

no

te

47WAsh’nutrition


assessment,programmedesignand/ormonitoringtool,butprimarily,itcouldhelpensuregoodgeographicalconcentrationofWASHprojectsintheareaswithhighprevalenceofundernutrition.Dependingonthecontext,therecanbedifferentwaysofdefiningthe priority intervention targeting:

1 high GAM prevalence*andhighratesofassociateddiseasessuchasdiarrheaandmalariawhendataareavailable–responsetonutritionalemergenciestosupportlifesavinginterventions;

2 high stunting prevalence* –longertermimpact,moredevelopment-orientedprogramming;

3 Areas where nutritional status is likely to deteriorate - programming focusing on prevention of undernutrition,thereforenotwaitingforhighprevalencecut-offvaluestointervene.

*See Chapter 1 for prevalence cut-off values of public health significance

IntegratedWASHandnutritionmappingimplieslookingatsomekey indicators,whichcanbeobtainedfromthesecondarydatasuchasKAP86surveysandannualreportsandproducingavisualexampleoftheirinteraction:

PrevalenceofGAM/SAMorstunting Accessanddistancetosafewatersource Accessanduseofadequateandsafesanitationfacilities Hygienepracticeswithinthepopulation,includinghandwashingatcriticaltimes Feedingandcarepracticesforinfantsandyoungchildren Prevalenceofdiarrhealdiseases/nematodeinfections/EED Prevalenceofstagnantwater (marshland,ricecultivation, largerainfallcreatingstandingwater)andbadlymanagedsolidwaste87

ProportionofhealthstructureslackingbasicWASHservices

Inaddition,dataonpatientoriginkeptatnutritionorhealthcentrescanbeusedtotracebackto identify villages where hotspots of undernutrition exist. Intelligent targeting ofWASH programming on this basis is an effective way to plancommunityWASHactivities.The resultingmapsprovidecontextually specific,evidenced-based information thatcouldbeusedinvariouswayswiththeaimofachievinggreaternutritionalimpact.Forexample,integratedmapscoulddemonstratethestronglinkbetweennutritionalstatusandtheWASHenvironmentwithinanareaandhighlightwherecertainkeyinterventionswouldbelikelytohavethegreatestimpactonundernutrition.88

eXAmple from the field 1

mapping of nutritional status and WAsh infrastructure in householdswith children under five years of age in bangladesh

Since 2006, Terre des hommes (Tdh) has been working to prevent acute undernutrition in the kurigram District of northern Bangladesh. The first programme to integrate Nutrition and WASH interventions was supported by UNICEF, the World Food Programme (WFP) and the Swiss Water and Sanitation Consortium (2011-2013). As a novel approach for WASH’Nutrition, the project utilized Geographic Information Systems (GIS) mapping by linking the database for nutritional status of children under five years with the database for household WASH infrastructure. In the peri-urban slum of Ward 1 (kurigram Municipality), Tdh produced seasonal maps of household prevalence of SAM and MAM, overlaying the location of project-supported household toilets and households with access to project tube wells. Although project funding did not permit 100% access to improved water source and toilets in Ward 1, the visualization of WASH infrastructure with cases of acute undernutrition helped identify neighbourhoods of concern for closer follow-up.

From 2013-2015 the integrated programme was scaled-up to cover large rural areas affected by floods in partnership with ECHO, WFP and the Swiss Water and Sanitation Consortium. The team used GIS mapping to represent SMART survey results at the Union Level.

In response to severe flooding in 2015, Tdh’s next step in kurigram District is to enhance collaboration with local authorities through a household census in flood-affected areas. The census will assist authorities to take decisions for resource allocation during relief and recovery interventions. In addition to demographic data, Tdh’s teams plan to map child nutritional status, early and high-risk pregnancies, birth registrations as well as WASH infrastructure and household location with respect to flood risk. As WASH infrastructure is costly, GIS mapping of census information is planned to help identify pockets of acute undernutrition where efforts and resources could be concentrated toward safely managed water and sanitation.

Documents

WASH’ NutritioN - Action Against Hunger · 2019-12-18 · WAsh’nutrition A practical guidebook list of figures Figure 1: DIFFERENT TYPES OF UNDERNUTRITION 17 Figure 2: CONCEPTUAL