WASHplus LEARNING BRIEF INTEGRATING WASH AND NUTRITION
WASHplus LEARNING BRIEFJUNE 2015INTEGRATING WASHAND NUTRITIONBackgroundUndernutrition is the underlying cause of 45 percent of childdeaths each year.1 The term undernutrition covers threeprimary anthropometric measures: stunting, which is lowheight for age; wasting, which is low weight for height; andunderweight, which is low weight for age. Despite targeted andcomprehensive nutrition-specific interventions, the persistentpresence of undernutrition globally has caused a renewed focuson underlying causes that go beyond lack of nutrients.2WASHplusrecognizes theimportanceof integratingwater,sanitation,and hygieneinto otherdevelopment priorities, such asnutrition, to achieve its objectiveof healthy households andcommunities.Inadequate access to clean water and unsafe sanitationand hygiene practices increase the risk of severe infectiousdiseases that can contribute to undernutrition.3 New researchis underway to further document and expand the evidencebase for the connection between water, sanitation, and hygiene(WASH) and undernutrition. Existing research suggests threekey pathways by which lack of WASH access and practicecontribute to undernutrition.4In Mali, WASHplus integratesnutrition and WASH.Children are screened and,if malnourished, referred tocenters where they can receivesupplemental food. The projectconducts community-ledtotal sanitation efforts andpromotes handwashing withsoap at critical times withchildren and parents.
1. Repeated bouts of diarrheaA vicious cycle exists between diarrhea and undernutrition: children withdiarrhea eat less and are less able to absorb the nutrients from their food;malnourished children are more susceptible to diarrhea when exposed tofecal material from their environment.2. Intestinal worm infection and malariaPoor environmental hygiene, including open defecation, propagates thevectors for both intestinal worms and malaria. Worms can affect nutritionalstatus by competing for nutrients and inducing intestinal bleeding, and likemalaria, can cause frequent anemia and diarrhea.Horizontalprogramming providesa more integratedand comprehensiveapproach toprogramming thatmirrors people’s lives.3. Environmental enteric dysfunction hypothesisEnvironmental enteric dysfunction (EED), also called environmentalenteropathy, is a chronic disease caused by constant fecal-oral contamination.The intestinal villi flatten, thus reducing their capacity for nutrient absorption,and the small intestinal lining becomes chronically inflamed. In addition, EEDis marked by increased gut permeability leading to a disturbed gut immunefunction. Thus, it is hypothesized that a body experiencing EED cannot absorb5nutrients because it is too busy fighting off diseases. EED may help explainwhy purely nutritional interventions have failed to reduce undernutrition inmany contexts.6,7Development programming often focuses on a single issue, such as WASHor nutrition, to target resources and maximize returns on investments thatcan be more directly measured by defined goals, objectives, and single-focusindicators. However, this type of programming does not foster solutions toaddress the complex problems faced by the poor and vulnerable, and oftenpromotes competition for scarce funding resources. Horizontal programmingprovides a more integrated and comprehensive approach to programmingthat mirrors people’s lives but can be difficult to measure and demonstrateresults, so donors are often reluctant to support such integration.WASHplus Approach to WASH–Nutrition IntegrationSince 2010, the USAID-funded WASHplus project has been engaged bothat the global and country levels in stimulating the discussion and improvingthe evidence base around integrating WASH into nutrition programming,sharing experiences and approaches to integrating the two sectors. WASHinterventions help reduce undernutrition by expanding the developmentcommunity’s focus to include both intermediate and underlying causes ofmalnutrition. WASH is now squarely embedded into USAID’s Multi-SectoralNutrition Strategy 2014-2025, and nutrition is a theme of the Agency’s Waterand Development Strategy 2013-2018.Global Knowledge Sharing: USAID/WASHplus global knowledge sharingactivities around WASH and nutrition include:¾¾ Publishing a brief WASH and Nutrition: Integrating Water, Sanitation andHygiene into Nutrition Programming in 2013 that provides an overviewof low-cost, high-impact WASH interventions that USAID implementingpartners can integrate into nutrition programming.¾¾ Collaborating with the World Health Organization and UNICEF to produce
a joint publication released in 2015 on how to integrate WASH activitiesinto nutrition programs. This practical publication is geared to nutritionimplementers in countries that are looking for ways to extend theirachievements in reducing undernutrition.¾¾ Collaborating with other USAID disciplines to incorporate WASHcomponents into nutrition assessment counseling and support (NACS), anapproach initially focused on HIV-affected households, but now expandedto the wider community in many countries implementing NACS.¾¾ Expanding integration linkages to include WASH, nutrition, and earlychildhood development, inter-related developmental areas critical tochildren under two reaching their full potential by being clean, fed andnurtured.SM¾¾ Facilitating conversations and knowledge sharing about WASH andnutrition with stakeholders in the donor and NGO communities throughvarious forums including:oMaintaining the USAID Community of Practice on WASH/Nutrition toencourage sharing and collaboration among practitioners interested inthis topic: ture.oOrganizing webinars on WASH and nutrition including: WASH, Nutritionand Early Childhood Development and Environmental Enteropathy andWASH: ning a WASH and nutrition blog on the WASHplus acilitating WASH-nutrition knowledge sharing at international ionsCountry Activities: In addition to global activities, WASHplus has integratedWASH and nutrition at different levels and through differentprogramming platforms in three countries: Bangladesh, Mali,and Uganda, using a behavior change approach called smalldoable actions (SDAs). WASHplus reviews and strengthensWASH within national nutrition policy and guidelines, surveys,curriculum, and capacity building documents.WASH and Nutrition in MaliThe two-year WASHplus program in Mali was designed asan integrated WASH and nutrition program from the start.District officials from the Ministry of Health identified the 180intervention communities as areas with high rates of stuntingand extremely poor access to and use of sanitation facilities. Inaddition to traditional nutrition-specific interventions such asthe management of moderate acute malnutrition, WASHplusis using SDAs to negotiate integrated WASH and nutritionmessages targeting mothers with infants.DEFINITION: SMALL DOABLEACTIONSA small doable action is a behaviorthat, when practiced consistentlyand correctly, will lead tohousehold and public healthimprovement. It is consideredfeasible by the householder, fromhis/her point of view, consideringthe current practice, the availableresources, and the particularsocial context. Although thebehavior may not be an “idealpractice,” a broader number ofhouseholds will likely adopt itbecause it is considered “feasible”within the local context. Thisapproach also has the potential tolead to further improvements inthe behavior, when/if resourcesbecome available.Cooking demonstrations inMali introduce recipes fornutritious complementaryfoods and emphasizethe importance ofhandwashing before foodpreparation.
WASHplus Mali createdthis counseling card toillustrate critical times formothers to wash handswith soap.Working through community health workers, WASHplus promotes anintegrated set of SDAs that draw on WASH and nutrition:¾¾ Handwashing with soap¾¾ Safe disposal of infant feces¾¾ Safe water treatment and storage¾¾ Exclusive breastfeeding¾¾ Complementary feedingIn Bangladesh trainedfacilitators meet withmother’s groups in courtyardsessions to discuss safe infantand young child feedingpractices; the importanceof handwashing beforecooking and feeding; andsafe disposal of adult, child,and animal feces. Facilitatorsalso negotiate small doableactions to improve WASHpractice.Other activities include efforts to increase access to sanitation throughcommunity-led total sanitation with sanitation marketing; screening andreferring malnourished children to health care facilities; rehabilitating watersupplies and promoting point-of-use water treatment; and conductingnutrition (cooking) demonstrations. The project is coordinated through thedistrict offices of the Ministry of Health in the Mopti Region. The lessonslearned from this pilot are generating dialogue and interest in integratedprogramming at the regional and national levels.WASH and Nutrition in BangladeshWASHplus is working at the national level to integratekey WASH indicators into nutrition activities andmonitoring, to both build the evidence base linkingWASH and nutrition programming and increase thefrequency of integrated programming, guided by thephrase, “What gets measured gets done.”In addition, WASHplus collaborates with other USAIDimplementing partners including SPRING and SHIKHAto reinforce handwashing before food preparation andfeeding as well as integrate food safety, sanitation, andsafe disposal of infant and animal feces into their moretraditional nutrition and livelihood activities. Thesenutrition projects focus on preventing stunting andmaternal and child anemia in the first 1,000 days andimproving infant and young child feeding. WASHplusprovided technical support and training on behavior
change to SPRING, which then rolled out this approach through its FarmerNutrition School program and Essential Health & Hygiene Actions initiativefor community health workers. SPRING has found statistically significantimprovements in handwashing practices through its monitoring efforts.As part of a comprehensive water and sanitation effort carried out in hardto-reach areas with WaterAid and local NGO outreach workers, WASHpluspromotes handwashing—particularly before cooking and feeding (installingtwo tippy taps, one at the latrine and the other at the cooking/ feeding area)—safe feces disposal, including an emphasis on improving leaky latrines and safedisposal of infant and animal feces; food hygiene; and safe water managementduring mothers’ courtyard sessions.Among the recommendedWASHplus small doableactions for food hygieneis to wash raw fruits andvegetables with soap or Jikand water before storingthem.WASH and Nutrition in UgandaIn Uganda, WASHplus worked through other USAID partners,primarily the FANTA, SPRING, and Community Connector projects,to integrate WASH components into nutrition and food securityprograms. WASHplus developed a modular WASH-nutrition trainingand offered both stand-alone and integrated sessions ranging fromhours to three days as opportunity allowed and needs .Through a collaborative process with SPRING and CommunityConnector, WASHplus helped develop SDAs for food hygiene,such as covering food, separating raw meats and vegetables, andreheating food until thoroughly steaming. These partners, in turn,trained government outreach workers and community volunteers.Using discussion guides and traveling video, the partners integratedSDAs around food hygiene and handwashing as part of government andvolunteer outreach worker activity. Other actions included reviewing andrevising NACS guidance and training at the national level, and promoting WASHenabling technologies such as tippy taps for handwashing (before cooking andfeeding and after defecation), and rainwater harvesting to increase access towater.Small Doable Actions for Keeping Food Safe:Serving and Food Storage18It is especially important to wash hands and food containers with soap and flowing water before handling food to minimise the risk ofgerms. Adhere to all personal hygiene practices like keeping fingernails short while handling food.SERVING Wash hands with soap before serving food. Cover food with net, tray, or cloth toprotect food from germs and flies. Store food on a high rack or shelf insidethe kitchen area or inside a cupboard Heat leftovers thoroughly until you see steamor bubbles. Stir to ensure they are heatedevenly. Construct a dish rack near dish washing Reheat leftovers only once then dispose. Dedicate two or three rags or nets for Cook all meat and eggs until boiled or wellcooked throughout.area to dry and store dishes.covering food. Store with clean dishes andutensils. Cover hot milk with a net or cloth.THE REPUBLIC OF UGANDAMinistry of Health Change covering cloth 2-3 times perweek. Wash used cloths with soap andwater. Store fresh and cooked food separately toavoid cross contamination. Store raw meat, poultry, fish separatelyfrom other foods in a bowl, plastic sack,or container. Wash raw fruits and vegetables with soapor Jik and water before storing them.WASHplus developed smalldoable actions to keepfood safe and incorporatedthem into a job aid foroutreach workers inUganda, with suggestionsfor storing, preparing, andserving.
ChallengesPlanned vs. Opportunistic IntegrationWASHplus and partners have made encouraging progress in integratingWASH into nutrition programs, however, the evidence to support particularapproaches is still evolving. When an integrated program is designed at theoutset with related project indicators for both WASH and nutrition equallyemphasized, then results can be clearly targeted and measured. Despite thebest intentions of sector and program managers, a primary challenge is that inmost nutrition programs, WASH is considered after the project’s initial design,so projects improvise by identifying strategic opportunities as they arise andincorporating one or two WASH components into an established nutritionprogram, often without the accompanying indicators appropriate to thoseinterventions. Without indicators to track implementation and contributionto the wider intervention package, it is difficult to quantify and justify theinclusion of WASH components. Currently, little evidence exists to show thatan integrated program is more effective and efficient than two concurrentvertical programs in the same region.Issues of MeasurementAttributing WASH-focused activities in reducing undernutrition is difficult.WASH programs typically do not collect anthropometric indicators such asstunting or wasting. Then, even if programs do collect such indicators, it isdifficult to determine to what extent the inclusion of WASH interventions hasinfluenced changes in nutritional status and growth. Measuring such changesrequires much more sophisticated evaluation design and analysis. In addition,detecting changes in growth patterns often requires timeframes longer thantypical WASH programs and funding cycles.Behavior change movesalong a continuum whenWASHplus applies its smalldoable actions approach.Keeping food, containers,and dishes clean and awayfrom animal contaminationis one step that moveshouseholds closer to theideal of a clean cookingenvironment.One-way vs. Two-way IntegrationWhile nutrition program managers at global and country level clearly graspthe vital contributions WASH makes to achieving nutrition outcomes, theyoften want to ensure that the integration is two-way—where WASH managersintegrate nutrition components and messages into WASH programs. Whilethis two-way approach may appear most collaborative, available evidencesupports only one-way integration of WASH into nutrition. Emphasizingaspects of improved nutrition is not necessary for achievingWASH goals, but infants and young children cannot grow wellwithout adequate WASH access and practice. Indeed, oftenWASH practitioners are water or sanitation engineers andmay have little connection to health at all. To date, the mostfeasible WASH actions we have identified are to coordinate
geographic co-location of WASH activities to increase access and practiceof WASH in areas that are nutritionally vulnerable, rather than incorporatenutrition messaging into WASH outreach.Targeting Communities vs. Targeting the Most VulnerableAdditional challenges to integration include “message overload” byincreasing the scope and number of behavioral objectives of nutritionactivities, stressing both outreach staff and the recipient households. Afinal challenge includes the apparent conflict in site selection and targeting,where sanitation programming targets entire communities becausemeasurable impact requires that communities are almost 100 percent opendefecation free, while nutrition interventions target the most vulnerablehouseholds.ConclusionsWASHplus anticipates that interest in expanding the integration of WASHinto nutrition programs will continue to grow over the next decade. Policyengagement is a vital step for integrating WASH and other interventions thatimpact nutrition programs. Having a national nutrition policy that recognizesthe importance of WASH for nutrition outcomes paves the way for thedevelopment of integrated programming at all levels. Donors, governments,and implementers should endorse and support an integrated approach. Staffin both sectors needs skills and knowledge to effectively implement integratedprograms.While enough evidence exists to support WASH and nutrition integration,more data is needed to demonstrate how and in which ways specific WASHmechanisms affect nutrition outcomes and determine which implementationmodalities are most likely to lead to strong and sustained impact. Anintegrated program should have a monitoring and evaluation framework withcorresponding WASH and nutrition indicators. However, when WASH activitiesare integrated into an existing nutrition program, WASH indicators need to beadded to the monitoring framework.Traditional WASH interventions focused on human excrement may need tobe supplemented with new approaches to break the fecal-oral transmissioncycle from animal feces, particularly in infants and young children. WASHplusis working to explore these programmatic approaches along with appropriatemonitoring frameworks. WASHplus anticipates that results from the integratedprogramming in Bangladesh, Mali, and Uganda will be validated and replicatedin other countries. As more countries and development partners implement arange of integrated approaches, the evidence base will grow.WASHplus targetsbreastfeeding motherswith nutrition and hygienemessages as they introducecomplementary and weaningfoods—a time of increasedexposure to microbes.To date, the mostfeasible WASH actionswe have identified are tocoordinate geographicco-location of WASHactivities to increaseaccess and practice ofWASH in areas that arenutritionally vulnerable.
ENDNOTES1.Black R et al. 2013. Maternal and Child Undernutrition and Overweight in Low-Income andMiddle-Income Countries. The Lancet. 382 (9890): 427–451.2.Bhutta et al. 2008. What Works? Interventions for Maternal and Child Undernutrition andSurvival. Maternal and Child Undernutrition Study Group. The Lancet. 371(9610):417-40.3.Black R et al. 2013.4.Humphrey. 2012. SHINE Sanitation, Hygiene, Infant Nutrition Efficacy Project (trial inZimbabwe). Study proposal. 2012. http://clinicaltrials.gov/show/NCT01824940. AccessedApril 27, 2014.5.Korpe and Petri. 2012. Environmental Enteropathy: Critical Implications of a PoorlyUnderstood Condition. Trends in Molecular Medicine. 18(6): 328-336.6.Humphrey J. 2009. Child Undernutrition, Tropical Enteropathy, Toilets, and Handwashing.The Lancet. 374: 1032–1035.7.Ngure et al. 2014. Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy,Nutrition, and Early Child Development: Making the Links. Annals of the New York Academyof Sciences, Volume 1308, Every Child’s Potential: Integrating Nutrition and Early ChildhoodDevelopment Interventions, 118–128.What is WASHplus?The WASHplus project supports healthy households and communities bycreating and delivering interventions that lead to improvements in water,sanitation, and hygiene (WASH) and household air pollution (HAP). This multiyear project (2010-2016), funded through USAID’s Bureau for Global Health andled by FHI 360 in partnership with CARE and Winrock International, uses at-scaleprogramming approaches to reduce diarrheal diseases and acute respiratoryinfections, the two top killers of children under age 5 globally.This brief is made possible by the generous support of the American peoplethrough the United States Agency for International Development (USAID)Bureau for Global Health under terms of Cooperative Agreement No. AIDOAA-A-10-00040. The contents are the responsibility of FHI 360, and do notnecessarily reflect the views of USAID or the United States Government.For more information, contact:WASHplus ProjectFHI 3601825 Connecticut Ave, NWWashington, DC 20009Tel.: 1 (202) 884-8496e-mail: washinfo@fhi360.orgwww.washplus.org
Nutrition Strategy 2014-2025, and nutrition is a theme of the Agency's Water and Development Strategy 2013-2018. Global Knowledge Sharing: USAID/WASHplus global knowledge sharing activities around WASH and nutrition include: ¾ Publishing a brief . WASH and Nutrition: Integrating Water, Sanitation and Hygiene into Nutrition Programming
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teachers talked individually with children about their car wash stories. The teachers wrote down each car wash story and later typed the stories on the computer. For example, Joseph (4 years, 7 months) dictated a story about a visit to a car wash: "My Mommy took me to a car wash. She didn't crash into the car wash. The worker washed our car.
WASH Work Plan Narrative - Year 1 3 P a g e TOPS WASH Program: Year 1 Narrative . water service utilities or best practices in implementing effective WASH-marketing programs. Linking to other WASH Actors 19. Coordinate with relevant stakeholders, including USAID's WASHPaLS project, FFP, WASH
the country office lead the development of the WASH budget brief. WASH staff should be familiar with the key policy and budget issues that need to be emphasized and also be able to identify useful indicators, relevant policy, strategy and planning documents, and budget data. In this regard, the WASH team should be responsible for: (i)
A key rationale for investing in WASH is the importance of WASH to other Sustainable Development Goal (SDG) outcomes. The essential inputs that the WASH sector provides, in the form of services and hygiene promotion, have multiple impacts beyond the WASH outcome itself, such as nutritional status, or education.
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