1. Tool 1A - Summary of Evidence for WASH and Nutrition Programming
JUNE 2016

2. The Pathways for WASH Contribution to Undernutrition

3. Pathways linking WASH and Nutrition
There are three direct pathways (related to vicious cycle of infection and undernutrition)
Repeated bouts of diarrhea
Intestinal worm infections
Environmental enteropathy
Indirect pathways are
The time spent collecting water and cost of purchasing water
The time and costs associated with caring for and seeking treatment for children sick with diseases of poor water and sanitation
The time spent being sick or fetching water affecting educational attainment
Check how many have heard of environmental enteropathy.

5. The Evidence for WASH Contribution to Undernutrition

6. WASH, diarrhea and soil-transmitted helminth infections
From the Global Burden of Disease study:
Improved WASH could prevent diarrheal deaths per year among children under five years of age, representing 58% of the total diarrhea deaths in this age group.
(Pruss-Ustun et al., 2014)
From meta-analyses:
Improving a range of WASH services and practices in households reduces the incidence of soil-transmitted helminth infections by, on average, one third.
(Ziegelbauer et al., 2012; Strunz et al., 2014)

7. WASH and Nutrition outcomes - 1
Observational studies:
Open defecation explained 54% of the international variation in child height, in contrast with GDP, which explained 29%
The effect was particularly strong for high population density areas and children under two years
WHO estimates that half of all cases of undernutrition are associated with repeated diarrheal or intestinal worm infections
Around one-quarter of stunting cases can be attributed to five or more episodes of diarrhea before the age of two years
Each episode of diarrhea may increase the possibility of stunting by 4%

8. Impact of open defecation on stunting
Sanitation affects stunting
Sanitation alone explains 54% of the international variation in child height
GDP only explains 29%
A child’s height-for-age predicts adult cognitive achievement and productivity
The observational evidence is strong.
Each data point is a collapsed DHS survey round (country-year), proportional to population.
Spears (2012) 8

9. The correlation between episodes of diarrhea and stunting
chances of stunting
The data shows the pooled analysis of nine studies that collected daily diarrhea morbidity and longitudinal anthropometry to determine the effects of the longitudinal history of diarrhea prior to 24 months on stunting at age 24 months.
The data covered a 20-year period and five countries.
diarrhea
Checkley et al. (2008) 9

10. WASH and Nutrition outcomes - 2
There is a strong association between poor WASH practices and poor Nutrition outcomes but the evidence for the positive impact of WASH interventions on undernutrition is more limited
One systematic review by Cochrane from 2013 found a small benefit from WASH interventions for the growth in length and height of children under five, with more significant impact on children under 24 months
BUT overall evidence is limited by the lack of published, rigorous studies, poor quality of the design of studies and evaluations, poor quality and coverage of interventions, and conpounding factors challenging the attribution of results

11. Improving the evidence base – Randomized, controlled trials underway
Sanitation Hygiene Infant Nutrition Efficiency (SHINE) Trial (Zimbabwe) – A cluster-randomized, community-based trial in two rural districts of Zimbabwe. It will determine the independent and combined effects of two interventions (improved WASH and improved infant feeding) on stunting and anemia among children followed from 12 weeks gestation to 18 months of life.
WASH benefits (Kenya & Bangladesh) – Two cluster-randomized, controlled trials to measure the impact of sanitation, water quality, handwashing and nutrition interventions on child health and development after two years of intervention in rural Bangladesh and Kenya. The studies are large in scope, with > 5,000 newborns per country.
MapSan (Maputo) – A controlled, before-and-after study of the health impacts of shared sanitation in a low-income urban setting. The 12-month follow-up phase on diarrhea, STH, height and weight in children finishes in January 2017.
STH = soil-transmitted helminth

12. The Evidence for WASH- Nutrition Synergized Service Delivery

13. Lessons learned from USAID WASHplus projects in Mali, Uganda and Bangladesh
Impact on stunting – programs with integrated WASH activities show greater impact on the reduction of stunting that programs with nutrition activities alone
Planned vs opportunistic integration – WASH is often added to the nutrition program after it starts and this makes it more difficult to track the results of integration
Attribution – challenges in measuring the extent to which nutritional outcomes are the result of WASH interventions or joint interventions
The USAID WASHplus approach focuses on:
The geographical convergence of WASH and Nutrition programs
Small doable actions (SDAs) in WASH which can be easily incorporated into Nutrition programs
The enabling environment for linking WASH and Nutrition, including government engagement, joint assessments and combined training of health and food security extension workers

14. Lessons learned from USAID WASHplus projects in Mali, Uganda and Bangladesh
Benefits of two-way integration – while two-way integration appears logical and more collaborative evidence strongly supports WASH contribution to nutrition outcomes, there is little evidence to suggest that integrating nutrition into WASH enhances WASH outcomes
Targeting scope – Nutrition activities target outreach staff and caregivers whereas many of the WASH activities target the whole community
Adapted sanitation interventions – Traditional WASH interventions to reduce open defecation may need to be supplemented with new approaches to break the fecal-oral transmission cycle from animal feces
The USAID WASHplus approach focuses on
The geographical convergence of WASH and Nutrition programs
Small doable actions (SDAs) in WASH which can be easily incorporated into nutrition programs
The enabling environment for linking WASH and Nutrition, including government engagement, joint assessments and combined training of health and food security extension workers

15. Ethiopia: Comparison of community-based interventions to reduce stunting
11 villages received either i) Nutrition, ii) Health, iii) WASH or iv) all 3 interventions over a five-year period
The WASH group was the only one to show a significant association between intervention activities and reduced prevalence of stunting
The villages receiving all 3 interventions showed the greatest improvements in access to water
But … results are not reliable due to the interference of other factors, especially the quality of programming (the WASH intervention was led by a strong team leader throughout)
The USAID WASHplus approach focuses on
The geographical convergence of WASH and Nutrition programs
Small doable actions (SDAs) in WASH which can be easily incorporated into nutrition programs
The enabling environment for linking WASH and Nutrition, including government engagement, joint assessments and combined training of health and food security extension workers

16. Peri-urban WASH and Nutrition Project in Bangladesh
Kurigram Municipality of Kurigram District, northern Bangladesh
The study describes the changes in the prevalence of malnutrition, comparing an integrated WASH intervention site and a comparison site.
WASH activities were integrated in only two of the nine wards with high prevalence of acute malnutrition. The other 7 were the control.