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WASH and Nutrition intergration
- 1. Integrating WASH and NUTRITION The WashPlus programby USAID Beatriz Erika T. Breva ,RND MS ApN HNF 254 Nutrition Programs
- 3. All forms ofundernutrition can, and should be prevented. Forms of Undernutrition
- 4. Conceptual Framework ofUndernutrition
- 5. Relationship between POORWASH and UNDERNUTRITION
- 6. Pathways by whichlack of WASH contributes to undernutrition 1. Repeated robust of diarrhea 2. Intestinal worm infection and malaria 3. Environmental enteric dysfuntion (EED)
- 7. Diarrhea • Results fromthe ingestion of pathogens from feces and from the lack of hygiene • Children with diarrhea eat less, absorb less nutrients → malnourished child → high risk for diarrhea • Increase risk of stunting
- 8. Intestinal worm andMalaria • Interfere with the nutrient uptake in children • Worm infection transmitted by eggs present in human feces • Malaria is transmitted thru the bite of a Plasmodium parasite infected Anopheles mosquito
- 9. EED • Cause byfrequent fecal oral contamination • Flatten intestinal villi, reduced capacity for nutrient absoprtion • Small intestinal lining become chronically inflamed • Cannot absorb nutrients because it’s busy fighting off disease
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- 13. Challenges 1. Planned vs.Opportunistic Integration 2. Issues of measurement 3. One-way vs. Two-way Integration 4. Targeting Communities vs. Targeting the Most Vulnerable
- 14. Conclusions • WASHplus anticipatesthat interest in expanding the integration of WASH into nutrition programs • more data is needed to demonstrate how and in which ways specific WASH mechanisms affect nutrition outcomes • traditional WASH interventions focused on human excrement may need to be supplemented • WASHplus anticipates that results from the integrated programming in Bangladesh, Mali, and Uganda will be validated and replicated in other countries
- 16. Citations • Arnold, B.F., Null, C., Luby, S. P., Unicomb, L., Stewart, C. P., Dewey, K. G., ... & Dentz, H. N. (2013). Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ open, 3(8), e003476. • Dodos, J. (2017). WASH’Nutrition: A practical guidebook on increasing nutritional impact through integration of WASH and nutrition programmes for practitioners in humanitarian and developent contexts. • Ngure, F. M., Reid, B. M., Humphrey, J. H., Mbuya, M. N., Pelto, G., & Stoltzfus, R. J. (2014). Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links. Annals of the New York Academy of Sciences, 1308(1), 118-128.
Editor's Notes
- #2 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).
- #4 Undernutrition Defined by UNICEF as “the outcome of insufficient food intake and repeated infectious diseases” ACUTE UNDERNUTRITION manifested by WASTING -indicated by LOW WEIGHT FOR HEIGHT, and/or presence of bilateral edemas and/or MUAC125 -DEVELOPS AS A RESULT of recent rapid weight loss MAY BE BROUGHT ABOUT by recent illness, inappropriate child care or feeding practice, or a combination of these factors CHRONIC UNDERNUTRITION displayed by STUNTING -indicated by LOW HEIGHT FOR AGE -chronic undernutrition is a process occuring over a longer time period between conception and 24mos of age -consequance of rolonged or repeated episodes of nutritional deficiencies and can also reflect exposure to repeated infection or other illnessess throughout the eraly yearsof life, THUS, compromising child’s growth UNDERWEIGHT -composite form of undernutrition defined by LOW WEIGHT FOR AGE MICRONUTRIENT DEFICIENCIES -”HIDDEN HUNGER” -occur when body does not have sufficient amounts of vitamin and mineral -due to insufficient dietary intake and insufficient absorption and or suboptimal utilization -top 10 causes if disease burden in the developing countries: Iron, Vit A, and Zinc
- #5 Despite targeted and comprehensive nutrition-specific inteventions, the persistent presence of undernutrition globally has caused a renewed focus on the underlying causes that go beyond lack of nutrients. The three main underlying causes of undernutrition, namely unsuitable or insufficient food intake, poor care practices and disease, are directly or indirectly related to inadequate access to water, sanitation and hygiene.
- #6 This figure illustrates multiple pathways, both direct and indirect, which demonstrate the dependence of nutritional status on the WASH environment. Poor WASH conditions facilitate ingestion of fecal pathogens which leads to diarrhea, intestinal worms and environmental enteric dysfunction. This directly relates to the body’s ability to resist and respond to sickness by affecting the absorption of nutrients and decreasing body’s immunity. Other water and sanitation-related illnesses such as malaria, dengue, leishmaniosis, trypanosomiasis, yellow fever, together with chronic poisoning due to poor chemical quality of water also contribute to the deterioration of nutritional status.
- #7 Research suggests 3 key pathways by which lack of WASH access and practice contributes to undernutrition Repeated robust of diarrhea Intestinal worm infection and malaria Environmental enteric dysfuntion (EED)
- #8 (instead of bulltes) Most often results from the ingestion of pathogens from feces that have not been properly disposed of and from the lack of hygiene Characterized by more than 3 bowel movements of liquid stools in a day A viscious cycle exists bet diarrhea and undernutrition: children with diarrhea eats less absorbs less nutrients making them malnourished, and malnourished children and more susceptible to diarrhea when exposed to fecal material -50% of undernourishment is associated to diarrhea - probability of dying from diarrheal disease among under 5 children is 10x higher if the child is affected by SAM Current evidence shows that with each diarrheal episode and with each day of diarrhea before 24mos, the risk of stunting increase -proportion of stunting attributable to five or more episodes of diarrhea before the age of 2 is 25%
- #9 (instead of bullets) Worms can affect nutritional status by competing for nutrients and inducing intestinal bleeding, and like malaria, can cause frequent anemia and diarrhea 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)
- #10 Environmental Enteric Dysfunction -also called environmental entheropathy (READ BULLETS) -chronic disease cause by frequent fecal-oral contamination It has been hypothesized that EED may be the primary causal pathway from poor sanitation to stunting as well as playing a role in the reduced efficacy of orally-administered vaccines such as polio and rotavirus. Associated with poor WASH environment and usually asymptomatic, EED may help explain why purely nutritional interventions have failed to reduce undernutrition in many contexts over the long term
- #11 The WASHplus project supports healthy households and communities by creating 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 and led by FHI 360 in partnership with CARE and Winrock International, uses at-scale programming approaches to reduce diarrheal diseases and acute respiratory infections, the two top killers of children under age 5 globally. WASH interventions help reduce undernutrition by expanding the development community’s focus to include both intermediate and underlying causes of malnutrition. WASH is now squarely embedded into USAID’s Multi-Sectoral Nutrition Strategy 2014-2025, and nutrition is a theme of the Agency’s Water and Development Strategy 2013-2018. Global Knowledge sharing: publishing program brief; collaborates with UNICEF and WHO to release publications onhow to integrate wash and nutrition; Collaborating with other USAID disciplines to incorporate WASH components into nutrition assessment counseling and support (NACS), an approach initially focused on HIV-affected households; Facilitating conversations and knowledge sharing about WASH and nutrition with stakeholders in the donor and NGO communities through various forum In addition to global activities, WASHplus has integrated WASH and nutrition at different levels and through different programming platforms in three countries: Bangladesh, Mali, and Uganda, using a behavior change approach called small doable actions (SDAs). WASHplus reviews and strengthens WASH within national nutrition policy and guidelines, surveys, curriculum, and capacity building documents. A small doable action is a behavior that, when practiced consistently and correctly, will lead to household and public health improvement. It is considered feasible by the householder, from his/her point of view, considering the current practice, the available resources, and the particular social context.
- #12 Cooking demonstrations in Mali introduce recipes for nutritious complementary foods and emphasize the importance of handwashing before food preparation. In Bangladesh trained facilitators meet with mother’s groups in courtyard sessions to discuss safe infant and young child feeding practices; the importance of handwashing before cooking and feeding; and safe disposal of adult, child, and animal feces. Facilitators also negotiate small doable actions to improve WASH practice.
- #13 WASHplus developed small doable actions to keep food safe and incorporated them into a job aid for outreach workers in Uganda, with suggestions for storing, preparing, and serving.
- #14 primary challenge is that in most nutrition programs, WASH is considered after the project’s initial design, so projects improvise by identifying strategic opportunities as they arise and incorporating one or two WASH components into an established nutrition program, often without the accompanying indicators appropriate to those interventions WASH programs typically do not collect anthropometric indicators such as stunting or wasting. Then, even if programs do collect such indicators, it is difficult to determine to what extent the inclusion of WASH interventions has influenced changes in nutritional status and growth While two-way approach may appear most collaborative, available evidence supports only one-way integration of WASH into nutrition. Emphasizing aspects of improved nutrition is not necessary for achieving WASH goals, but infants and young children cannot grow well without adequate WASH access and practice. conflict in site selection and targeting, where sanitation programming targets entire communities because measurable impact requires that communities are almost 100 percent open defecation free, while nutrition interventions target the most vulnerable households
- #15 WASHplus anticipates that interest in expanding the integration of WASH into nutrition programs will continue to grow over the next decade. -Policy engagement, promotion of integrated approach, training for staff and workers While enough evidence exists to support WASH and nutrition integration, more data is needed to demonstrate how and in which ways specific WASH mechanisms affect nutrition outcomes and determine which implementation modalities are most likely to lead to strong and sustained impact. -development of monitoring tool As more countries and development partners implement a range of integrated approaches, the evidence base will grow
- #16 Illustrates links between SDG 2, 3, and 6