Making water, sanitation, and hygiene programs nutrition sensitive

Making water, sanitation, and hygiene (WASH) nutrition sensitive does not require a paradigm shift.

Rather, it requires that interventionists and program planners adhere to WASH behavioral objectives and align programs with the multiple pathways of feco-oral transmission relevant to the target population. More specifically, here is how we can ensure that WASH programs are nutrition sensitive:

A 9-year-old girl collects rainwater for drinking in Bangladesh. Credit: Johns Hopkins Photoshare

A 9-year-old girl collects rainwater for drinking in Bangladesh. Credit: Johns Hopkins Photoshare

1. Focus on nutritional outcomes: WASH programs inherently address crucial underlying drivers of fetal and child nutrition and development, and are therefore fundamentally nutrition sensitive. However, they can be further leveraged for nutrition actions when they are implemented in a manner that protects women’s time; reducing the time women spend fetching water can affect the time they have available for childcare and other activities associated with improved consumption (Pickering and Davis 2012; WHO, UNICEF, and USAID 2015).

2. Target the first 1,000 days: The first 1,000 days after conception have been identified as a critical point in a child’s development because of the rapid process of linear growth, which mirrors brain development. WASH programs targeted to this age group are therefore more likely to achieve nutritional outcomes and prevent the developmental deficits associated with early growth faltering.

3. Pay attention to the causal linkages between WASH and nutritional outcomes: Conditions of poor WASH can affect nutritional status through diarrheal disease and parasitic infections. Recently, it has been hypothesized that a subclinical gut disorder called environmental enteric dysfunction is a primary mediator of the association between WASH, and stunting and anemia (Humphrey 2009). Focusing only on clinical disease outcomes may thus underestimate the impact of WASH interventions. As such, WASH programs should be implemented with time frames that permit changes in nutritional outcomes to be realized and evaluated for additional outcomes related to diarrhea incidence and prevalence.

4. Align WASH interventions with these causal linkages: Preventing children’s ingestion of fecal microbes in the first 1,000 days should be an express objective of nutrition-sensitive WASH programs. Research in rural Zimbabwe (Ngure et al. 2013; Mbuya et al. 2015) and elsewhere suggests that the feco-oral transmission pathways for adults differ from those of toddling children, who engage in mouthing and exploratory play—for example, geophagy and consumption of chicken feces. This result suggested that a nutrition-sensitive WASH (or baby WASH) intervention should:

• reduce the environmental microbe load through household sanitation and hygiene;
• reduce fecal transmission via hands through washing of caregivers’ and children’s hands with soap;
• improve drinking water quality through improved access to protected water sources and hygienic methods of household water treatment and storage;
• promote exclusive breastfeeding for the first six months of life to ensure nutrient adequacy and exclude potentially contaminated non–breast milk liquids and foods;
• avoid child fecal ingestion during mouthing and exploratory play by ensuring a clean play and infant feeding environment; and
• provide hygienically prepared and stored complementary food fed using clean utensils and hands.

This is an excerpt from Panel 6.4 of the 2016 Global Nutrition Report.