Better WASH, better nutrition outcomes.

2022.
WASH Context Overview:
 Globally, 1.42 billion people including 450 million children live in areas of high or
extremely high-water vulnerability – JMP, 2019
 A research carried out by UNICEF listed South Sudan amongst the 180 Countries
experiencing high/extremely high-water Vulnerability; 54% of children in South Sudan
live in areas with high/extremely high-water vulnerability.
 The decades of conflict coupled with resent events in climate change have deepened the
vulnerability status of South Sudan as water facilities were flooded and contaminated.
 Conflict not only separates people from their safe water sources but also very common,
parties to conflict deliberately damage, restrict or contaminate water sources.
 Less than 3% of the Worlds water resources is fresh and is increasingly growing scarce.
78% of livelihoods including agriculture (accounting for 70% of freshwater use) depend
on water (UNESCO 2016).
 Research has shown that water scarcity, fluctuating temperature and rainfall patterns
reduce productivity of land, significantly contributing to malnutrition.

South Sudan WASH Coverage – UNICEF WASH bulleting

 Only 40% of population have access to safe water

 Only 10% of the population have access to improved sanitation
 61% off the population still practice Open Defecation.
How the above situation impacts on nutrition

 Around the world millions of children suffer from undernutrition – an outcome of

insufficient food intake or nutrient absorption, and or repeated infectious diseases.
 Although undernutrition is often considered to be an issue of food security, evidence shows
that availability of sufficient, quality food does not necessarily result in improved nutrition.
Other health and environmental factors, including poor water, sanitation and hygiene
(WASH) result in repeated infections, which affect how nutrients are absorbed and used
within the body. Poor nutrition status further increases susceptibility to disease, thereby
creating a vicious cycle. Thus, poor WASH significantly contributes to undernutrition.
 Undernutrition is both a cause and a consequence of poverty and is a major contributor to
maternal and child mortality in the shorter term as well as noncommunicable diseases
(NCD) in the longer term.
 It negatively affects all aspects of an individual’s health and development and impedes
economic and social progress at the community and national levels.
  Together with simple nutrition interventions that combat undernutrition, WASH
interventions such as handwashing with soap, and use of hygienic latrines or toilets, access
to safe water and good sanitation and hygiene play a big role in combating undernutrition.
Because of that, the global nutrition community has repeatedly called for greater attention
to and investments in WASH to improve nutrition outcomes. Integrating WASH
interventions into nutrition actions can make a difference.
 Although investments in larger water and sanitation infrastructure will require resources
outside the remit of nutrition, there is need for more advocacy and planning of co-location
of nutrition and WASH efforts.

Causes of undernutrition related to WASH???

Every day, over 700 children under age of 5 die from diarrhea linked to unsafe water, sanitation
and poor Hygiene – Pruss-Ustun et al (2019). Diarrhea lowers nutrients uptake in children resulting
in stunted growth and other irreversible impacts on children’s physical and mental development.
About 144 million children under 5 Worldwide are Stunted - Pruss-Ustun et al (2019).

Data from rural Africa show that females born during severe droughts suffer the impacts their
whole lives, growing shorter (World Bank 2017).
WASH improvement frameworks:

WASH programmes will have a greater and more sustainable impact 0n nutrition
when three elements are combined: an enabling policy and institutional
environment, access to good-quality hardware and services, and demand
creation/uptake of services. Below is how sustainable WASH can bring about
improved child growth.
WASH Interventions critical for combating undernutrition/malnutrition .

Hygiene promotion.

 Hand hygiene; this is the most feasible for nutrition programmes to integrate and
implement. In the household, handwashing with soap should be encouraged at critical times
e.g. before preparing food or cooking, before eating or feeding a child, after cleaning a
child’ bottom, after visiting the toilet/defecation and each time one touches dirty
environment.

 Similar to other WASH interventions, handwashing requires the adoption of consistent and
correct behavior. Targeting the physiological factors that are responsible for the formation
of habitual behavior (e.g. risk, attitudinal, ability or maintenance beliefs) is an effective
means to create and sustain such a habit.

 Handwashing should be done correctly to effectively remove pathogens from hands. This
can best be achieved by handwashing with adequate quantities of flowing water and soap
or, alternatively, hand rubbing with an alcohol-based solution and ash.

 To be effective, handwashing should last 40–60 seconds for water and soap or 20–30
seconds for hand rubbing with an alcohol-based solution, and the action should follow the
recommended. Setting up dedicated hand washing facilities is critical for good hygiene.
Food hygiene

Though breast milk is the most nutritious and safe food for infants and young children.
Complementary feeding is recommended for children beyond six months or in circumstances
where the mother is taking medication and can’t breast feed. In such cases, breast milk substitutes
should be prepared safely to avoid contamination, following WHO recommendations (WHO/FAO,
2007). Complementary foods, while continuing to breastfeed for up to 2 years or beyond (WHO,
2013a). Care should be taken to safely prepare complementary foods, as several studies in low-
resource settings have shown that food given to young children is often highly contaminated with
faecal pathogens (Islam et al., 2013; Touré et al., 2013). WHO has these Five Keys to Safer Food
that can be taken to prevent food contamination.

 Handwashing, cleaning key surfaces and utensils, protecting food preparation areas from
insects, pests and other animals).
 Separate raw and cooked food.
 Cook food thoroughly.
 Store food at safe temperature.
 Use safe water and raw material.
Environmental hygiene

Floors and ground surrounding the house can be a source of contamination for young children as
they begin to explore their environments by crawling, walking, putting objects in their mouths or
directly consuming dirt or soil.

Studies have found high levels of faecal indicator bacteria in the soil of areas where young children
play and on the hands of children (Ngure et al., 2013). Animal faeces, such as chicken, dog or cow
faeces, often present in the yards of houses have been found to harbor high loads of pathogens,
thus presenting an additional potential source of contamination, as children have been observed
directly ingesting faeces found in household compounds (Ngure et al., 2013).

As a result, whereas most hygiene promotion programmes have traditionally focused on the
handwashing practices of mothers, researchers have begun to develop and evaluate the impact of
interventions aimed at containing animals and washing babies’ hands (Ngure et al, 2013)

Important environmental hygiene practices;

 Keep animals away from areas where the food is prepared and served to the child, child
play areas and water sources.
 Regularly clear compound of any animal or child faeces, at least daily.
 Control disease vectors such as flies, mosquitoes, cockroaches and rats by covering food,
 Improving drainage and safely disposing of garbage and non-reusable materials into a
waste receptacle or protected pit.
 Clean key surfaces. This may include cleaning latrines, basins and kitchen floors and
surfaces with soap and water and possibly disinfecting after cleaning with a dilute bleach
solution, if available. •
 Provide safe areas that can be regularly cleaned where children can play.
Sanitation: Safe disposal of faeces, the foundation for reducing pathogens in the environment
and protecting human health, begins with household access to hygienic sanitation facilities that
safely remove and treat faeces.

Faeces must also be safely transported to a designated disposal/treatment site or returned to the
environment in a way that prevents human exposure to the faeces. A holistic approach to
addressing faecal risks from source to safe use or disposal is facilitated through sanitation

Interventions to improve access to and use of sanitation facilities

 Engage communities in a process to develop and implement sanitation safety planning to

safely manage, dispose of and utilize excreta.
 Support sanitation campaigns using social mobilization strategies, such as community-
based or sanitation marketing approaches targeting both household- and community-level
improvements. E.g. community led total sanitation, an approach that aims at ending open
defecation.
 Mentor small-scale sanitation businesses to improve supply chain efficiency and marketing
skills and improve product and service models for sanitation so they are more affordable
and attractive to consumers.
 Leverage financial schemes such as village savings and loans and microfinance institutions
to provide financing for household sanitation improvements.
 Develop communal, public and institutional sanitation services, as well as faecal sludge
management systems, to ensure access for all and to protect the environment from faecal
pollution.
 Integrate hygiene practices with sanitation facility improvements by locating a
handwashing device with water and soap near a latrine to remind and enable users to wash
hands after defecating.
 Sanitation for other vulnerable groups
 Other vulnerable populations (pregnant women, older people, immunocompromised
people and people with disabilities) may constitute a quarter or more of the popu lation
(representing one or more individuals in a family). These populations may also
disproportionally suffer from poor nutrition, and thus solutions to enable their access to
and use of sanitation are especially important. Their right to access is upheld in the UN
Human Right to Water and Sanitation (UN, 2010) as well as the UN Convention on the
Rights of Persons with Disabilities (UN, 2006).

Sanitation interventions for vulnerable populations

 Making latrine or toilet structural improvements such as providing poles, support stools or
ropes that can support a person trying to get to the latrine and may make it easier to use.
 Clearing obstacles from the path to the latrine

Sanitation interventions appropriate for infants and toddlers

 Promote use and safe disposal of diapers (nappies) and safe cleaning of reusable cloth used
to contain faeces.
 Improve and promote access to “enabling products” such as potties and hoes that facilitate
getting faeces into latrines for safe disposal.
 Make latrines “child friendly” by partially covering the latrine hole with a small board or
use a slab with a child-sized hole to prevent children from falling into the pit, improving
light and ventilation.
Water quantity and quality (Access to safe drinking-water)

 Improving access to safe drinking-water involves constructing or improving water supply

systems or services, such as providing piped water on-site, public standpipes, boreholes,
protected dug wells, protected springs and rainwater. It is estimated that 15–20 L of water
per person per day is needed for consumption, food preparation, cleaning, laundering and
personal hygiene (sphere standard handbook). Similar to sanitation safety planning, long -
term approaches to address and manage risks associated with unsafe drinking-water ought
to be addressed.

Household water treatment and safe storage

 Although improving access to safe drinking-water remains an essential development goal,

low-cost strategies to treat and safely store drinking-water at the point of consumption can
provide an intermediate solution while longer-term infrastructure improvements are being
planned and implemented.
 Household water treatment (HWT) and safe storage (HWTS) technologies, also known as
point-of-use technologies, include a range of devices or methods used to treat water in the
home or other settings, such as schools and health care facilities.
 A growing body of evidence demonstrates that the use of HWT products improves the
microbiological quality of household water and reduces the burden of diarrheal disease in
users (Clasen et al., 2007; Waddington et al., 2009; WHO, 2014b).
 In addition, there is evidence to suggest that distribution of HWTS through health care
providers can improve uptake of antenatal services and thereby further support improved
nutritional outcomes (Wood, Foster & Kols, 2012).
 Even safe water at the source can be easily contaminated during collection, transport and
storage. Ideally, water in the home should be stored in a clean container with a lid and a
narrow neck to prevent contamination of the water with hands.
 If the container does not have a narrow neck, the water can be served with a ladle that is
stored in a clean place (not on the floor). Water may also be stored in a bucket with a tightly
fitting lid and poured from the container.
 The most common and proven methods of HWT include filtration, chemical disinfection
(e.g. chlorination), heat, including boiling, pasteurization and ultraviolet (UV) radiation,
and combined flocculant/disinfectant.
 In order to achieve health benefits, HWT must effectively remove the pathogens that cause
diarrheal disease in a particular setting and be used correctly and consistently by
populations with unsafe drinking-water.
 To ensure that technologies sufficiently protect users, WHO has established the
International Scheme to Evaluate Household Water Treatment Technologies, which
coordinates the independent and rigorous evaluation of HWT technologies according to
health-based performance criteria (WHO, 2011)
 In addition, selection of HWT technologies should consider pathogens that may be
especially problematic for vulnerable groups. For example, those living with HIV are
especially vulnerable to diarrheal disease and therefore the recommended method of
treatment (e.g. filters) should remove this pathogen (Peletz et al., 2013).
 The correct and consistent uses of technologies are equally important and depend on
several factors, including ease of use, cultural preferences and motivations, and cost and
availability of the product, including spare parts and consumables. Programmes aiming to
implement HWTS should consider these factors and provide ongoing behavioral change
and user support.
Linkages between WASH and Nutrition;

Integration of WASH and nutrition should not be seen as a goal in itself, but a strategic tool to
enable the achievement of better nutritional outcomes. There are many types and levels of
integration, and the goals, capacities and enabling environment will help determine the a ppropriate
level of integration.

Integration may take different forms. It is important to build on what exists, making incremental
efforts to increase integration when worthwhile, document and reflect on lessons learnt and further
refine and improve joint efforts.

Integration could include one, some or all these aspects:

 Geographic co-location of nutrition and WASH efforts in areas with high incidence of
diarrhea, undernutrition and inadequate water, sanitation and hygiene
 Single implementing partner or contract mechanism
 Merged budgets
 Joint design process including more than one sector/subsector •
 Interdisciplinary management team/steering committee
 Consolidated reporting.

Integrated programming can happen at many levels (national, subnational, between or within
agencies), and opportunities to integrate may arise as programmes evolve. The most appropriate
interventions to include will be context specific. However, in many instances, promotion of
hygiene practices, such as handwashing with soap, is feasible within nutrition programmes.
Examples of key actions for integrating WASH into Nutrition.

 Understand the situation: review existing data, policies and strategies.

 Leverage existing policies and strategies to advocate for greater integration and inform
joint planning, objective setting and monitoring.
 Strengthen existing nutrition policies and inform the development of new nutrition policies
with an appropriate focus on WASH.
 Identify champions and advocates for WASH and nutrition integration.
 Engage with stakeholders in joint planning.
 Establish and build a working relationship between nutrition and WASH actors.
 Target WASH programmes in areas of high nutritional need.
 Train health and nutrition staff to promote and demonstrate key WASH practices in
ongoing nutrition work.
 At the community and household levels, promote improved nutrition and WASH practices
and reinforce the practices using multiple communication channels.

Examples of WASH practices for integration in MIYCN

 Wash hands before food preparation and feeding

 Handle food safely (e.g. reheat food before serving infants)
 Treat and safely store water for all individuals and especially for young children who eat
complementary foods and drink water
 Remove animal and human faeces from environment (e.g. dispose of infant faeces safely)
 Build and use latrines, engaging with WASH actors for technical support
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