Post on 05-Aug-2018
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WASHNutritioNA prActicAl guidebook on increAsing nutritionAl impAct through integrAtion of WAsh And nutrition progrAmmesFor practitioners in humanitarian and development conteXts
2WAshnutritionA practical guidebook
3WAshnutrition
A practical guidebook
WAshnutrition
A prActicAl guidebook on increAsing nutritionAl impActthrough integrAtion of WAsh And nutrition progrAmmes
For practitioners in humanitarian and development conteXts
4WAshnutritionA practical guidebook
5WAshnutrition
A practical guidebook
tAble of contentsstAtement on copYright 6AcknoWlegements 7hoW to use this guidebook 8foreWord 9lists of figures - tAbles - boXes - mAps 10 list of AcronYms 12
1 the bAsics of undernutrition And WAsh 141. Definingundernutrition 172. Themaincausesofundernutrition 193. The1,000dayswindowofopportunity 204. Undernutritionconsequences 205. Addressingundernutrition 226. GlobaltrendsinundernutritionandWASH 27
2 linking nutritionAl outcomes With the WAsh environment 301. NutritionalstatusandtheWASHenvironmentrelationship 332. Keypathwaystoundernutrition 343. ContributingWASH-relateddiseases 374.WASHinterventionseffectsonhealth 38
3 WAshnutrition strAtegY And progrAmming 421. AligningWASHandNutritionprogramming 452. Integration 463. Focusonthemotherandchilddyad 544. Emphasisonbehaviourchange 575. Coordinationofstakeholders 596. EnsuringaWASHminimumpackage 62
4 integrAting Activities At different levels And conteXts 701. Attheindividualandhouseholdlevel 732. Atcommunitylevel 843. Atinstitutionallevel(healthcentres&schools) 954. Atnationallevel 1045. Integratinginterventionsinemergencies 107
5 monitoring And evAluAtion of integrAted interventions 1161.Monitoringintegratedactivities 1192. Impactevaluationofintegratedinterventions 122
6 moving toWArds uptAke 1241. Operationalresearch 1272. Capacity-buildingandtools 1283. Communicationanddissemination 1304. Targetedadvocacy 132
progrAmmAtic resources 138
6WAshnutritionA practical guidebook
stAtement on copYright
COPYRIGHTACFInternational-January2017Reproductionispermittedprovidingthesourceiscredited,unlessotherwisespecified.Ifreproductionoruseoftextualandmultimediadata(sound,images,software,etc.)aresubmittedforpriorauthorization,suchauthorizationwillcancelthegeneralauthorizationdescribedaboveandwillclearlyindicateanyrestrictionsonuse.
This document covers the humanitarian activities implemented with the financial support of the European Union. TheviewsexpressedhereinshouldnotinanywaybetakentoreflecttheofficialopinionoftheEuropeanUnion.TheEuropeanCommissioncannotbeheldresponsibleforanyusethatmaybemadeoftheinformationcontainedinthisdocument
NON-ResPONsIbIlITY ClauseThepresentdocumentaimstoprovidepublicaccesstoinformationconcerningtheactionsandpoliciesofACF.Theobjectiveistodisseminateinformationthatisaccurateandup-to-dateonthedayitwasinitiated.Wewillmakeeveryefforttocorrectanyerrorsthatarebroughttoourattention.Thisinformation:
issolelyintendedtoprovidegeneralinformationanddoesnotfocusontheparticularsituationofanyphysicalperson,orpersonholdinganyspecificmoralopinion;
isnotnecessarilycomplete,exhaustive,exactorup-to-date;
sometimesreferstoexternaldocumentsorsitesoverwhichtheAuthorshavenocontrolandforwhichtheydeclineallresponsibility;
doesnotconstitutelegaladvice.Thepresentnon-responsibilityclauseisnotaimedatlimitingACFsresponsibilitycontrarytotherequirementsofapplicablenationallegislation,oratdenyingresponsibilityincaseswherethesamelegislationmakesitimpossible.
Author: JovanaDodos(jovana.dodos@gmail.com),PublicHealthconsultant-ExpertiseandAdvocacyDepartment,WASHsector,ACF-FranceDesign:ClineBeuvinPhoto on cover PAge: B.Stevens/i-ImagesforActionAgainstHunger
ActionContrelaFaim2017,14/16BoulevarddeDouaumont-CS80060-75854ParisCedex17-France
Asoftcopyoftheguidebookmaybedownloadedat:www.actioncontrelafaim.org
7WAshnutrition
A practical guidebook
AcknoWledgements
ThisguidebookhasbeenpreparedbyActionContrelaFaim-ACFandfinanciallysupportedbytheEuropeanCommissionsDirectorate-General for EuropeanCivil Protection andHumanitarianOperations (ECHO).An international group ofmorethan 20 experts in the fields ofWASH,Nutrition andHealth, togetherwith numerous field practitioners, contributed toitsdevelopmentbyparticipating in thepeer reviewprocess,providing technicalexpertise, insightful reflections, ideasandmaterials.Theauthorisdeeplygratefulfortheirsupport.Sincerest thanks are extended toACF-FranceDirection of Expertise andAdvocacy (Dr S. Breysse,Dr J. Lapgue - Projectcoordinator)andACF-US(ZviaShwirtz,EllynYakowenkoandGezahegnMetosso)forholdingtheproject.ThankstotheACFmissionsinSenegalandAfghanistanforhostingfieldvisits,providinginputsandsharingtheirinvaluablefieldexperienceinWASHandNutritionintegration.ThanksgotoMsMarielleLabadens,HeadoftheWater,SanitationandHygieneProgrammeinSenegal,andMrFedericoSoranzo,WASHHeadofDepartmentinAfghanistan,fortheirimmensesupportinorganizingthefact-findingmissions.SpecialthankstoUNICEFWCARO(FranoisBellet),ECHO-Dakar(DamienBlanc)andUNICEFNew-York(DianeHollandandLizetteBurgers).
THe PeeR RevIew GROuPMrBenHobbs, International Campaign Manager, Generation NutritionMsClaireGaillardou,WASH - DRM Advisor for West and Central Africa, Action Against Hunger MrDamienBlanc,Water, Sanitation and Hygiene Expert, ECHOMsDianeHolland,Nutrition Advisor, UNICEFMrFranoisBellet,WASH Specialist, UNICEF Regional Office for West and Central Africa, Regional WASH Group CoordinatorMrFranckFlachenberg,Environmental Health Technical Advisor, Concern WorldwideDrJeanLapgue,Senior WASH-DRM Advisor, Action Against Hunger MsMarie-SophieWhitney,Global Nutrition Expert, ECHOMsMargaretMontgomery,WASH Technical Officer, WHOMrNicolasVilleminot,Senior WASH Technical Advisor, Action Against Hunger MrPabloAlcaldeCastro,Senior WASH Advisor, Action Against Hunger MsRachelLozano,Nutrition survey and prevention advisor, Action Against Hunger MsRenukaBery,Senior Programme Manager, WASHplus project, FHI 360MrRonClemmer,Strategy & Business Development Manager, WASH, FHI360MsRuthNashipayiSituma,Nutrition Specialist, UNICEF
THe CONTRIbuTORsMrArnoCoerver,Global WASH Advisor, Malterser International MsJonaToetzke,GIZ/ACF WASH and Nutrition consultantMrJohannesRck,Project Coordinator WASH & Nutrition, German Toilet OrganizationMrJohnBrogan,Water Sanitation & Hygiene Advisor, Terre des hommesMsJordanTeague,Associate Director for WASH Integration, WASH AdvocatesMsKateGolden,Senior Nutrition Advisor, Concern Worldwide MsLailaKhalid,Grants Coordinator, Action Against Hunger PakistanMrMarkButtle,Senior Humanitarian WASH Advisor, Save the ChildrenMsMarieTheresBenner,Senior Health Advisor, Malteser InternationalMsMeganWilson-Jones,Policy Analyst: Health & Hygiene, WaterAidMrDrMohammadMonirulHasan,Centre for Development Research (ZEF), University of BonnMsMonicaRamos,WASH and Shelter Expert, Middle East and Eurasia, ECHOMsStephanieStern,Responsable ACF-LAB, ACF-FranceMrStephanSimon,Advisor Basic Infrastructure, WASH, Deutsche WelthungerhilfeMrTanguiLeziart,WASH Programme Manager, Action Against Hunger MrTomDavis,Global Health/behaviour Change consultant and former Chief Programme Officer of Food for the Hungry
8WAshnutritionA practical guidebook
hoW to use this guidebook
Undernutrition is a multi-sectoral problemwith multi-sectoral solutions. By applying integrated approaches, the impact,coherenceandefficiencyoftheactioncanbeimproved.
ThisoperationalguidebookdemonstratestheimportanceofbothsupplementingnutritionprogrammeswithWASHactivitiesandadaptingWASHinterventionstoincludenutritionalconsiderationsi.e.makingthemmorenutrition-sensitiveandimpactfulonnutrition.IthasbeendevelopedtoprovidepractitionerswithusableinformationandtoolssothattheycandesignandimplementeffectiveWASHandnutritionprogrammes.Apart fromencouragingthedesignofnew integratedprojects, theguidebookprovidessupportforreinforcingexistingintegratedinterventions.Itdoesnotprovideastandardapproachorstrictrecommendations,butratherideas,examplesandpracticaltoolsonhowtoachievenutritionandhealthgainswithimprovedWASH.IntegratingWASHandnutritioninterventionswillalwayshavetobeadaptedtospecificconditions,opportunitiesandconstrainsineachcontext.
Theguidebookprimarilyaddressesfieldpractitioners,WASHandNutritionprogrammemanagersworking inhumanitariananddevelopmentcontexts,andrespondstotheneedformorepracticalguidanceonWASHandnutritionintegrationatthefieldlevel.Itcanalsobeusedasapracticaltoolfordonorsandinstitutions(suchasministriesofhealth)toprioritisestrategicactivitiesandfundingoptions.
THe CONTeNT Is ORGaNIzed as fOllOws
chAPter 1outlinesthebasicsofundernutritionandprovidesabriefoverviewofthekeyconceptsrelevantforWASHandNutritionintegratedprogramming.
chAPter 2 providestherationalebehindlinkingnutritionalstatuswithWASHenvironmentandexplainshowWASHinterventions,bypreventinginfectionanddisease,helpreduceundernutrition.Ashortsummaryofexistingevidence-basedknowledgeispresentedinthisChapter.
chAPter 3 isorganizedaroundthefivepillarsofWASHNutritionstrategy.ItgivesoperationalguidanceandadviceonhowtointegrateWASHandnutritioninterventions,highlightingpossiblechallengesandproposingstrategiesforovercomingthem.
chAPter 4 describesapractical implementationof integratedactivitiesatdifferent levels(household,community,national)andindifferentsettings(healthandnutritioncentres,schools).SpecialattentionisgiventointegratingWASHandNutritioninemergencycontexts.
chAPter 5 proposes a framework formonitoring andevaluating integrated interventions, togetherwith a setofindicatorsthatcanbeusedtomeasureprogressandimpact.
chAPter 6coversadvocacyforWASHandnutritionintegration,communication,capacity-buildingforprojectstaffandtheoperationalresearch.
the ProgrAmmAtic resources section contains a collection of practical tools and examples from fieldprojectstohelpintegrationeffortsateachphaseofaclassicalprojectcycle.
Theguidebookalsocontainsanumberofnotes,boxeswithtipsandfurthercomments, linkstowebpagesandsuggestedreading.Throughouttheguidebookyouwillfindpracticalexamplesfromthefield(casestudies),collectedfromACFmissionsandthecontributors.
Youwillfindlistsoffigures,boxesandtablesp.10.
9WAshnutrition
A practical guidebook
foreWord
Undernutrition remains a significant global public health threat. It affects millions of children and contributes to an estimated 3.1 million child deaths each year, accounting for over a third of all deaths of children. Adequate nutrition in early childhood is essential for healthy physical growth and brain development. Nutritional deficiencies during this period can not only result in disease and death, but also can have long term consequences on cognitive and social abilities, school performance and work productivity.
When children are undernourished they are more likely to suffer from diarrheal diseases and other infections. Emergency and development settings where undernutrition is high often have inadequate and unsafe water, sanitation and hygiene (WASH) services which further compounds the problem. The evidence, although limited, does indicate a clear link between WASH and nutrition outcomes, with, for example, an association between open defecation and stunting.
Proven, simple interventions exist to prevent undernutrition and diarrhea, even in settings that are challenged by poor sanitation, lack of hygiene, and unsafe drinking water. The 2015 WHO/UNICEF/USAID document, Improving nutrition outcomes with better water, sanitation and hygiene: Practical solutions for policy and programmes, serves as an important foundation document for understanding the evidence, the interventions and approaches for joint WASH and nutrition actions. This practical field guide by ACF complements this initial publication by providing more detailed, frontline examples from over 30 countries on when, where and how to integrate efforts. It is targeted at humanitarian and development workers looking for simple but effective strategies for achieving nutrition targets, in part, through better WASH.
Addressing undernutrition and meeting the 2025 Global Nutrition Targets will require a multi-sectoral approach with a strengthened focus on improving WASH. Furthermore, the Development Goals, including Goal 6 on Water and Sanitation, Goal 3 on Health and Goal 17 on Partnerships provide an opportunity to target, more effectively, resources and attention on the benefits of safe WASH for nutrition and health, and development more broadly. In short, no child ought to suffer from undernutrition and through smart, targeted joint action on WASH and nutrition, millions of deaths can be prevented.
MargaretMontgomery,Water, Sanitation, Hygiene and Health, WHO
ZitaWeisePrinzo,Nutrition for Health and Development, WHO
10WAshnutritionA practical guidebook
list of figuresFigure 1:DIFFERENTTYPESOFUNDERNUTRITION 17
Figure 2: CONCEPTUALFRAMEWORKOFUNDERNUTRITION 19
Figure 3: UNDERNUTRITIONTHROUGHOUTTHELIFECYCLE 21
Figure 4: NUTRITION-SPECIFICANDNUTRITION-SENSITIVEINTERVENTIONS 22
Figure 5: NUTRITIONSECURITYAPPROACH 23
Figure 6: GLOBALTRENDSINCHILDSTUNTINGANDWASTING 27
Figure 7: RELATIONSHIPBETWEENPOORWASHANDCHILDUNDERNUTRITION 33
Figure 8: MEDIANAGE-SPECIFICINCIDENCESFORDIARRHEALEPISODESPERCHILDPERYEARFROMTHREEREVIEWSOFPROSPECTIVESTUDIESINDEVELOPINGAREAS 35
Figure 9: VICIOUSCYCLEBETWEENINTESTINALINFECTIONSANDUNDERNUTRITION 35
Figure 10: DIFFERENCEBETWEENHEALTHY(LEFT)ANDEED-INFECTEDINTESTINE(RIGHT) 36
Figure 11: REDUCTIONINDIARRHEALMORBIDITY 38
Figure 12: THEF-DIAGRAM-Fecal-oralrouteofdiseasetransmissionandhowWASHprovisioncanpreventit 39
Figure 13: EFFECTOFIMPROVEMENTSINDRINKINGWATERANDSANITATIONONDIARRHEADISEASERISK 40
Figure 14: INCREASINGLEVELSOFMULTI-SECTORALINTEGRATION 46
Figure 15: RELEVANTSTAKEHOLDERSFORWASHANDNUTRITIONINTEGRATION 60
Figure 16: HUMANITARIANCLUSTERSANDTHEIRCOORDINATION 61
Figure 17: ALLOCATEAPROTECTEDSPACEFORCHILDRENTOPLAY,LIMITINGTHELIKELIHOODOFTHEMINGESTING SOILORANIMALFECES 75
Figure 18: THECLEANHOUSEHOLDAPPROACH 75
Figure 19: ACOUNSELLINGCARDHIGHLIGHTSWHENTOWASHHANDSWITHSOAP 77
Figure 20: POSTERUSEDTODISCUSSKEYFOODHYGIENEPRACTICESBYACFCHAD 81
Figure 21: GLOBALCOVERAGEOFWASHINHEALTHCAREFACILITATES 95
Figure 22: THEFITFORSCHOOLACTIONFRAMEWORK 101
Figure 23: HOLISTICAPPROACHTOWASHANDNUTRITIONINTEGRATION 105
Figure 24: DRMCYCLE,CONTINUUMANDCONTIGUUM 109
list of tAblestAble 1: CUT-OFFVALUESANDANTHROPOMETRICINDICATORSOFUNDERNUTRITION 18
tAble 2: MORTALITYRISKSFORWASTINGAND/ORSTUNTING 20
tAble 3: NON-ExHAUSTIVEExAMPLEOFWASHINTERVENTIONS 26
tAble 4: INCORPORATINGWASHELEMENTSINTONUTRITIONASSESSMENTSANDVICEVERSA 50
tAble 5: COMMONBARRIERSANDCHALLENGESINWASHANDNUTRITIONINTEGRATION 53
tAble 6: ILLUSTRATIVECRITERIAFORPOPULATIONTARGETING 54
tAble 7: TENSTEPMODELFORASSISTINGBEHAVIOURCHANGE(ABC) 58
tAble 8: WASHMINIMUMPACKAGEFORHOUSEHOLDS 63
tAble 9: WASH MINIMUMPACKAGEFORHEALTHANDNUTRITIONCENTRES 65
tAble 10: WASH MINIMUMPACKAGEFORMOBILECLINICS 67
tAble 11: INTEGRATINGWASHINTONUTRITIONCOUNSELLINGANDHEALTHPROMOTION 86
tAble 12: WHODEFINITIONOFENVIRONMENTALMANAGEMENT 91
tAble 13: WHOSTANDARDSONWATER,SANITATIONANDHYGIENEINHEALTHCARE 96
tAble 14: ExCRETADISPOSALOPTIONSFORYOUNGCHILDRENINEMERGENCIES 112
tAble 15: EVALUATIONOFANINTEGRATEDPROJECT 122
tAble 16: ADVOCACYTOOLSFORPROMOTINGWASHANDNUTRITIONINTEGRATION 133
11WAshnutrition
A practical guidebook
list of boXesboX 1: DESIGNCHARACTERISTICSOFNUTRITION-SENSITIVEINTERVENTIONS 23
boX 2: COMMUNITYMANAGEMENTOFACUTEMALNUTRITION(CMAM)APPROACH 24
boX 3: WASHNUTRITIONTARGETING 45
boX 4: SEASONALCALENDAR 49
boX 5: DIFFERENTAGESTAGESANDWASHPROGRAMMING 55
boX 6: IMPROVINGCHILDRENSPARTICIPATIONINWASHBEHAVIOURCHANGEPROGRAMMES 57
boX 7: ASSISTINGBEHAVIOURCHANGE(ABC)MODEL 58
boX 8: BABYWASHMESSAGES 74
boX 9: 5CRITICALSTIMESFORHANDWASHINGWITHSOAP 77
boX 10: 5KEYSTOSAFERFOODBYTHEWHO 80
boX 11: BREASTFEEDINGTHEULTIMATEHYGIENEINTERVENTION 81
boX 12: LINKINGWASHANDNUTRITIONWHENDELIVERINGOVERALLCOMMUNITYSERVICES 84
boX 13: REDUCINGANIMALWASTECONTAMINATION 93
boX 14: MAINHYGIENEPROMOTIONMESSAGESUSEDINTHEACFMISSIONINCHADDURINGTHEWEEKLYHYGIENE PROMOTIONSESSIONSINHEALTHCENTRES 98
boX 15: PUBLICHEALTHAPPROACHTONUTRITION 105
boX 16: OVERCOMINGTHEHUMANITARIAN-DEVELOPMENTDIVIDEWHENADDRESSINGUNDERNUTRITION 108
boX 17: CHILD-TO-CHILDAPPROACHOVERVIEW 113
boX 18: MONITORINGINDICATORSSUGGESTEDBYWASHNUTRITIONSTRATEGY 120
boX 19: EFFECTIVENESSOFADDINGAHOUSEHOLDWASHCOMPONENTTOAROUTINEOUTPATIENTPROGRAMME OFSEVEREACUTEMALNUTRITION 127
boX 20: INTERNATIONALDAYSOFSHAREDINTERESTFORWASHANDNUTRITIONSECTORS 130
boX 21: MISSINGINGREDIENTSREPORTWATERAIDANDSHARECONSORTIUM 135
boX 22: GERMANYSSPECIALINITIATIVEONEWORLDNOHUNGER 137
list of mApsmAP 1: DIARRHEADEATHSUNDER5 28
mAP 2: WASTINGCHILDRENBYREGION 28
mAP 3: PERCENTAGEOFCHILDRENUNDER5WHOARESTUNTED 28
mAP 4: OVERLYINGGAMRATESWITHACCESSTODRINKINGWATERINCHAD 48
mAP 5: NIGER,2000:STUNTING,DIARRHEAANDWASH 142
12WAshnutritionA practical guidebook
list of AcronYmsAbc ASSISTINGBEHAVIOURCHANGEAri ACUTERESPIRATORYINFECTIONSAscAo VILLAGE-BASEDMANAGEMENTASSOCIATIONSbmgF BILLANDMELINDAGATESFOUNDATIONbmZ GERMANFEDERALMINISTRYFORECONOMICCOOPERATIONANDDEVELOPMENTccts CONDITIONALCASHTRANSFERScgv CAREGROUPVOLUNTEERchAst CHILDRENHYGIENEANDSANITATIONFORTRANSFORMATIONclts COMMUNITYLEADTOTALSANITATIONcmAm COMMUNITYMANAGEMENTOFACUTEMALNUTRITIONDFiD BRITISHDEPARTMENTFORINTERNATIONALDEVELOPMENTDhs DEMOGRAPHICHEALTHSURVEYSecho EUROPEANCOMMISSION,DIRECTORATE-GENERALFOREUROPEANCIVILPROTECTIONAND
HUMANITARIANOPERATIONSecosAn ECOLOGICALSANITATIONeeD ENVIRONMENTALENTERICDYSFUNCTIONenn EMERGENCYNUTRITIONNETWORKevis ExTREMELYVULNERABLEINDIVIDUALSeWP ENDWATERPOVERTYFchvs FEMALECOMMUNITYHEALTHVOLUNTEERSFh/m FOODFORTHEHUNGRY/MOZAMBIqUEFti FAECALLYTRANSMITTEDINFECTIONSgAc GLOBALAFFAIRSCANADAgAm GLOBALACUTEMALNUTRITIONgDP GROSSDOMESTICPRODUCTgems GLOBALENTERICMULTI-CENTRESTUDYgis GEOGRAPHICINFORMATIONSYSTEMgnc GLOBALNUTRITIONCLUSTERgWn GERMANWASHNETWORKhFA HEIGHTFORAGEhh HOUSEHOLDShhWt HOUSEHOLDWATERTREATMENThmis HEALTHMANAGEMENTINFORMATIONSYSTEMhWts HOUSEHOLDWATERTREATMENTANDSAFESTORAGEicn2 SECONDINTERNATIONALCONFERENCEOFNUTRITIONiDA IRONDEFICIENCYANAEMIAiDPs INTERNALLYDISPLACEDPEOPLEiYcF INFANTANDYOUNGCHILDFEEDINGiYFc INFANTANDYOUNGCHILDRENFEEDINGKAP KNOWLEDGE,ATTITUDEANDPRACTICElbW LOWBIRTH-WEIGHTlrrD LINKINGRELIEF,REHABILITATIONANDDEVELOPMENTmAm MODERATEACUTEMALNUTRITIONmDg MILLENNIUMDEVELOPMENTGOALSmirA MULTI-SECTORINITIALRAPIDASSESSMENTmou MEMORANDUMOFUNDERSTANDINGmsF MDECINSSANSFRONTIRESmuAc MID-UPPERARMCIRCUMFERENCEmus MULTIPLE-USEWATERSERVICES
13WAshnutrition
A practical guidebook
ncD NON-COMMUNICABLEDISEASEngo NON-GOVERNMENTALORGANIZATIONntD NEGLECTEDTROPICALDISEASESntu NEPHELOMETRICTURBIDITYUNITSors ORALREHABILITATIONSOLUTIONPeFsA v PAKISTANEMERGENCYFOODSECURITYALLIANCEVPhAst PARTICIPATORYHYGIENEANDSANITATIONTRANSFORMATIONPlW PREGNANTLACTATINGWOMENProconu PROGRAMMECOMMUNAUTAIRENUTRITIONNELrutF READY-TO-USETHERAPEUTICFOODSsAm SEVEREACUTEMALNUTRITIONsbcc SOCIALBEHAVIOURCHANGECOMMUNICATIONSsDc SWISSAGENCYFORDEVELOPMENTANDCOOPERATIONsDg SUSTAINABLEDEVELOPMENTGOALSsiDA SWEDISHINTERNATIONALCOOPERATIONAGENCYslts SCHOOL-LEDTOTALSANITATIONsm SANITATIONMARKETINGsun SCALINGUPNUTRITIONsusAnA SUSTAINABLESANITATIONALLIANCEsWA SANITATIONANDWATERFORALLPARTNERSHIPStDh TERREDESHOMMEStot TRAININGOFTRAINERStssm TOTALSANITATIONANDSANITATIONMARKETINGunhcr UNITEDNATIONSHIGHCOMMISSIONERFORREFUGEESuniceF UNITEDNATIONSINTERNATIONALCHILDRENEDUCATIONFUNDurenAs OUTPATIENTNUTRITIONRECOVERYANDEDUCATIONUNITSvhsgs VILLAGEHEALTHSUPPORTGROUPSWAsh WATER,SANITATIONANDHYGIENEWFA WEIGHTFORAGEWFh WEIGHTFORHEIGHTWFP WORLDFOODPROGRAMMEWho WORLDHEALTHORGANIZATION
14WAshnutritionA practical guidebook
Jova
na D
odos
A
cF
sen
egal
, 201
5
1the bAsics
of undernutrition and WAsh
1. defining undernutrition
2. the mAin cAuses of undernutrition
3. the 1,000 dAYs WindoW of opportunitY
4. undernutrition consequences
5. Addressing undernutrition
6. globAl trends in undernutrition And WAsh
15WAshnutrition
A practical guidebook
the
bA
sics
of
un
der
nu
trit
ion
an
d W
Ash
16WAshnutritionA practical guidebook
end hunger, Achieve food securitY And improved nutrition And promote sustAinAble Agriculture
ensure heAlthY lives And promote Well-being for All At All Ages
ensure AvAilAbilitY And sustAinAble mAnAgement of WAter And sAnitAtion for All
WAshnutrition illustrAtes the link betWeensustAinAble development goAls 2, 3 And 6
17WAshnutrition
A practical guidebook
1. defining undernutrition
Defined by UNICEF as the outcome of insufficient food intake and repeated infectious diseases, undernutrition isoneoftheworldsmostseriousbut leastaddressedproblemswithdirectshort-and long-termhealth effects. Undernutrition includes being underweight for onesage, dangerously thin for ones height wasted, too short for onesage - stunted, and deficient in vitamins and minerals - micronutrientdeficiencies.1 These conditions often overlap - for example, a stuntedchild may also bewasted and have micronutrient deficiencies, whichincreasesariskofmorbidityandmortality.2
Figure 1: DIFFERENTTYPESOFUNDERNUTRITION
Normal height for age
normAl WAstingLow weight for height
underWeightLow weight for age
stuntingLow height for age
Source: World Vision (2015), Definitions of hunger
Acute undernutrition is indicated by a lowweight-for-height(WFH), when compared to the WHO growth standards (socalledZscores),3and/orpresenceofbilateraledemasand/orMUAC
18WAshnutritionA practical guidebook
chronic undernutrition or stunting is indicatedbya lowheight-for-age (HFA).Asopposedtoacuteundernutritionwhichreflects recent nutritional status, chronic undernutrition is a process occurring over longer term in the period betweenconceptionand24monthsofage.Itisaconsequenceofprolongedorrepeatedepisodesofnutritionaldeficiencies(energyormicronutrients)andcanalsoreflectexposuretorepeated infectionorother illnessesthroughouttheearlyyearsof life,compromisingthegrowthofachild.5
underweight isacompositeformofundernutritiondefinedbya lowweight-for-age (WFA)whencomparedtotheWHOgrowthstandards.Underweight iseasier tomeasurethanweight-for-heightorheight foragebecause itdoesnt requireaheightmeasurement,butitisgenerallyconsideredinferiortothemeasuresaboveasitdoesntindicateifachildiswastedorstunted.
Micronutrient deficiencies,alsoknownashidden-hunger,occurwhenthebodydoesnothavesufficientamountsofvitaminormineral due to insufficient dietary intake and/or insufficient absorption and/or suboptimal utilizationof thevitamin ormineral.WHOranksdeficienciesofzinc,ironandvitaminAinthetop10causesofthediseaseburdenindevelopingcountries.Micronutrientdeficienciesaffectthesurvival,health,developmentandwell-beingofthoseaffected.6
All forms of undernutrition can and should be prevented.
tAble 1: CUT-OFFVALUESANDANTHROPOMETRICINDICATORSOFUNDERNUTRITION
Anthropometric indicators used to measure child growth and nutritional statusPrevalence cut-off
values of public health significance
AcuteunDernutrition
sAmWFHindicator