December the fourth leading cause of mortality among young

December 2017Understanding Current Approaches,Gaps, and Opportunities in theWASH/Nutrition NexusDipti RaiINTERN, PATH2BackgroundUndernutrition in children is a major problem in low- and middle-income countries, which putsthe age group younger than 2 years, in particular, at risk of dying from diarrhea and other infectiousdiseases (1). In 2016, of all the 159 million children under 5 years old living with stunting, 56%lived in Asia and 38% in Africa, and of the 52 million children under 5 with wasting, 69% livedin Asia and 27% in Africa (2). An estimated 45% of all deaths of children in the age group of under5 was attributable to undernutrition in 2011(1).On the other hand, diarrhea alone is equally a significant health threat to children. According to arecent estimate of global data published in The Lancet, despite the reduction of diarrheal mortalityrates in children by 34.3% and incidence by 10.

4% (3), diarrhea killed about 499,000 childrenyounger than 5 in 2015, making it the fourth leading cause of mortality among young children inthe world (4).About 88% of deaths from diarrheal diseases is attributable to unsafe drinking water, inadequatewater supply for maintenance of hygiene, and lack of access to sanitation together (5).Most importantly, diarrhea in combination with other Water, sanitation, and hygiene (WASH)related factors affects the nutritional outcome as shown in Fig. 1 (6).Fig. 1 Underlying components of WASH that affect nutritional outcomes in children.3Diarrhea leads to loss of appetite, malabsorption of nutrients fromthe gut, and increased metabolism (7).

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Hookworm infections canlead to anemia, in both pregnant women and children, which inturn increases the risk of preterm delivery and low birthweightbabies (7). Women who have already experienced malnutritionare more likely to become malnourished mothers and give birthto underweight babies. Such babies are susceptible toundernutrition and infectious diseases (including death),establishing an intergenerational cycle of undernutrition (1), asillustrated in Fig. 2.

About 80% of deaths from diarrheal disease occur in children less than 2 years of age (8), aschildren between 6 months and 2 years have relatively more exposure to enteric pathogens oncethey start crawling and putting things in their mouth (7). Undernourished children in this group arealso more prone to suffering from frequent, severe and prolonged episodes of enteric infectionswhich can lead to irreversible stunting and impaired cognitive ability (7).While nutrition specific interventions alone do not seem to improve the overall nutritional outcomein children (9) integrated nutrition interventions with prevention and control of infections haveindicated more benefits in terms of improving nutritional outcome in children (10).WASH interventions reduce the pathogen load in the environment, which reduces the incidence ofdiarrheal disease and intestinal worm infections in children.

This ensures healthy gut function andbetter nutrient absorption, and decreases susceptibility to other infectious diseases, therebyfacilitating healthy development and growth of children (11). Considering the importance of thefirst two years of life as a window of opportunity for growth promotion (12), and the impact thatWASH and nutrition interventions alone have had so far, an integrated approach ofWASH/nutrition program targeting children in this age group could be more beneficial..Source: Save the Children. Nutrition in the First 1,000 Days: State of theWorld’s Mothers 2012.Fig. 2 The intergenerational cycle ofgrowth failure4ObjectiveThe overall objective of this study was to explore existing integrated WASH/nutritionprogrammatic approaches, leading evidence/results, barriers/challenges, and areas for futureresearch through desk research and interviews with subject matter experts.

MethodologySemi-structured, in-depth interviews with WASH and nutrition experts were conducted. Theinterviews explored approaches taken in integrating WASH and nutrition programs, barriers andchallenges to integration, and recommendations for integration ideal for addressing the needs ofchildren younger than 2 years. Secondary data collection involved a review of published data.

The study was designated as a nonhuman study by the Research Determination Committee ofPATH. Interviewees were purposively selected based on their professional experiences andexpertise. Six interviews were conducted, five on Skype and one in person. Five people declinedthe request, but one of them provided helpful documents and links for further study. The interviewswere coded and analyzed for emergent themes.FindingsExisting evidences for integration from literatureA retrospective analysis of data from 145 countries conducted in 2014 concluded that improvedwater and sanitation in low- and middle-income settings could prevent 361,000 deaths annuallyfrom diarrheal disease among children less than 5 years of age, which is 58% of total diarrhearelateddeaths and 5.5% of deaths in that age group (13). A multi-country study showed that anexposure to a higher cumulative burden of diarrhea owing to poor sanitation during the first 2 yearsof life was associated with 25% of stunting (14).

A study in Peru showed that children at 24 monthsof age, living with the worst conditions for water source, water storage, and sanitation, were 1 cmshorter and suffered 54% more diarrheal episodes as opposed to children of the same age groupliving in the best conditions (15). The same study showed that a height deficit of 0.9 cm at 24months of age could be attributed to inadequate sewage disposal (15).

5A cluster randomized trial of 121 villages in Mali showed that severe stunting in children could bereduced by 22% and the risk of severe underweight by 35% with reduction of open defecation(16). In Bangladesh, children from clean households were found to have 22% lower stuntingprevalence than children from contaminated households (17).A study done in 2012 in Niger concluded that therapeutic food alone does not address malnutritionunless adequacy of the water supply is considered. The association between adequacy of watersupply and the length of stay in a therapeutic feeding center of Medicins Sans Frontiers for 1518children from 20 villages showed that children exposed to adequate quantity and quality of watersupply had the shortest stay in the feeding center (OR=0.97). Furthermore, both quantity(OR=0.64) and quality (OR=0.44) of water were independently associated with shorter stay in thefeeding center (18).

A systematic review of fourteen studies from 10 LMICs published in 2013 evaluated the effectvarious WASH interventions on nutritional status of children under age 18 years of age andconcluded that solar disinfection of water, provision of soap, and improvement of water quality,significantly contributes to increased height in children less than 5 years of age (19).The Strengthening Household Ability to Respond to Development Opportunities (SHOUHARDO)Project of United States Agency for International Development (USAID) in Bangladesh (2006-2010), which focused on WASH and nutrition interventions for children between 6 and 23 monthsof age and pregnant and lactating women, showed that stunting decreased from 56% to 40% in the6- to 24-month age group, and none of the children under 5-year age group experienced increasesin stunting over three years. USAID’s Good Start Program in Peru (1999-2004), based on aparticipatory community-based program integrating WASH, nutrition, and early childhooddevelopment over four years, successfully reduced stunting from 54% to 37%, while decreasinganemia prevalence from 76% to 52% and serum retinol, an indication of vitamin A status, from30% to 5% (11).

Programmatic barriers and challengesLack of funding, collaboration/coordination, and donor support; siloed working mechanism;6knowledge gaps; and poor governance, plans and policies/strategies, paucity of convincingevidences, emerged as the main themes in terms of barriers for program intergration.I. FundingAll participants expressed that lack of funding for multi-sectoral integrated programs is the majorbarrier. A similar finding was reported from a study in which funding for WASH and nutritionprograms was mentioned to come either from different donors or from a donor but with differentgoals and expectations (20). Interestingly, another report mentioned the existence of competitionfor funding between WASH and nutrition programs (21).II. Governance and policyVertical and segregated government implementation structures for WASH and nutrition,especially at the ministry level, were discussed as the other main challenge.

WASH and nutritionstakeholders consult with the respective ministries and program coordination mechanisms oftenlack across ministries. Most participants mentioned that integration is often weakest at the policylevel.This is not different from what participants mentioned in another study, which also cited the needfor supportive institutional arrangements and funding at both national and subnational levels foreffective implementation of policies (21).III. Knowledge and learningAll participants agreed that lack of training and knowledge-sharing among sectoral experts isanother barrier to integration. Experts are preoccupied with their assigned responsibilities andtraining outside of their own field is not prioritized.IV. Lack of evidenceMajority of the participants agreed that there are limited data to show that an integratedWASH/nutrition approach can result in better health outcomes.

Similar view was noted by relevanexperts in a study done by Teague et al. and a study conducted in Cambodia (18, 20).7Additionally, many participants also mentioned that the choice of indicators for the outcomemeasurement is equally challenging. Observation of physical changes takes time, while invasivetechniques to determine gut health might not be feasible in all settings.V. StaffThe majority of participants mentioned that technical specialists are needed in different roles nomatter how integrated the program is. Usually people have limited technical capacity beyond theirsector of primary responsibility.

Interestingly, one report mentioned that WASH practitioners areengineers with little connection to health at all (22).Most study participants believed that an integration is easier at subnational levels, especially at thecommunity level. In contrast to this it has been reported that from a practical point of view, it ischallenging for community beneficiaries to participate in multiple activities, or learn informationabout multiple topics at the same time when programs are integrated (20, 22).

The need of certainkind of incentives has been mentioned to encourage staff participation in the integration processat the subnational levels (18, 19).VI. Planning, design, and strategyMany participants stressed that focus on sector-specific objectives is a barrier to integration whenit comes to planning co-location of a program. WASH programs often target entire communitiessince the measurable impact requires that communities have 100% access, while nutritioninterventions often target the most vulnerable population (22). This notion was shared by a fewparticipants who believed that targeting whole communities versus the most vulnerable populationis another challenge in the integration process.All participants noted that measurement of any impact in general requires more time than what isavailable within short project cycles, as noted in the two other studies (21, 22).

It was also noticedthat generating evidence regarding specific changes attributable to WASH or nutrition requiresspecial study, which is beyond what routine project monitoring and evaluation does (21).8Participants also mentioned about Action contre la Faim’s WASH Nutrition practicalGuidebooka which encourages integrated service delivery for the “mother/caretakermalnourishedchild” dyad. Programmatic approaches like “Baby WASH”, “SUAHARA””Clean Household,” are discussed in the book and were also mentioned by the experts.Recommendations from participantsParticipants made the following recommendations for targeting children under 2 years of life,based on their experiences with successful programs.I. Strengthening of cross-sectoral coordination and collaboration is necessary to bring ministries,researchers, and stakeholders together to rethink the implementation model.II.

Integrated programs are successful only when accepted at the policy level and internalized bythe government; therefore, it is important to engage government from planning point throughall stages of implementation.III. Programs should be integrated in such a manner that neither of the one gets overshadowed bythe other.

IV. In situations where a single donor is unwilling to support an integrated program, seeking fundfrom multiple donors for an integrated program was hinted as a possibility.V. Messages to prevent children from coming in contact with environmental pathogens shouldcover both WASH and nutrition aspects like promotion of breastfeeding, and consumption oflocally available nutritious foods.VI.

Staff training and capacity-building should take place at the subnational level, with particularfocus on the community level.VII. During project design, sufficient time should be planned for impact evaluation and ensuringsustainability of programs.ConclusionMost integrated programs focus either on nutrition or WASH as the first priority, and the othercomponent is either overshadowed or considered as a complementary program.

There is a lack ofrigorous evidence regarding the outcomes of integrated WASH/nutrition interventions on childrena Available from: than 2 years.

This is because most programs have been vertical. Lack of funding for multisectoralprograms, effective cross-sectoral coordination, and comprehensive strategies to addressthe integration process are the main barriers to the integration process.Strategies to address these barriers and challenges could be the subject of future research involvinga larger sample size, which was beyond the scope of this study due to time constraints.