Special focus on nutrition-sensitive programming

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Waddington review as randomised or clusterrandomised
controlled trials and 19 as non-randomised
controlled trials. irteen described hygiene,
four water supply, three sanitation and
seven multiple interventions.
Findings
e first stage of review judged that, at the ‘more
than possible’ or ‘likely’ level, 22% of interventions
involved substantially more actions than the SR’s
label indicated; 37% resulted in substantial additional
impacts beyond reduced diarrhoea morbidity;
and unforeseen actions by individuals,
households or communities substantially contributed
to the impacts in 48% of studies. In 44%,
it was judged that these additional impacts and
actions would have substantially affected the intervention’s
effect on diarrhoea morbidity, its
level, social distribution or sustainability. ese
impacts and actions would likely be found to be
more common in studies not so narrowly selected
as were those the Waddington review drew on.
In the second stage of review, the authors
identify six impact pathways each present in three
or more studies and which were not considered by
the original SR. e first relates to intervention
complexity: agency staff add actions to an intervention
in response to local circumstances; in some
cases, interventions are sited where an earlier one
had been implemented and build on its effects. In
both cases, the intervention-as-experienced involves
more than indicated by the label. An example is a
Guatemalan program described by the Waddington
review as “hygiene education” but which comprised
11 topics including nutrition (promotion of weaning
foods, breastfeeding and agricultural diversification)
and the recognition and treatment of diarrhoea,
in addition to hygiene issues. e study only monitored
hygiene behaviours and in relation to diarrhoea
reduction (Torun, 1983). e intervention’s
impact on diarrhoea may be overestimated if the
additional or prior actions are ignored.
e second impact pathway relates to the
direct multiple benefits of interventions. By doing
one thing, interventions may affect different causes
of ill-being. For example, a water supply intervention
in Buenos Aires connected shantytown
households to the urban system, increasing the
quality and reliability of the water they could
access, contributing thereby to reduced diarrhoea
burdens, and saving them time and money spent
fetching and procuring water (Galiani et al, 2008).
e non-diarrhoea benefits will likely be valued
in their own right and may increase people’s commitment
to support and maintain the intervention,
enhancing sustainability.
e third pathway relates to unintended negative
consequences of interventions. Agencies make
operational decisions on where and when to implement
interventions affected by political influence,
corruption and ease of access. e result may be
an anti-poor distribution of benefits, exacerbating
inequalities. In the Democratic Republic of Congo,
diarrhoea incidence declined significantly in villages
to which piped water was delivered compared
with those relying on existing sources (Tonglet et
al, 1992). Pipes were laid near main roads, apparently
for ease during construction, which is also where
higher socio-economic status households were
concentrated. us, those least at risk of diarrhoea
captured most benefits. e intervention’s impact
was also overestimated because baseline differences
between villages were not accounted for.
A fourth pathway was identified in several
studies with evidence of unanticipated benefits
from people using access to water for food and
improved nutrition. Water supply interventions
enable beneficiaries not only to avoid water-related
diseases but also to irrigate kitchen gardens,
throughout the year. Women started to do this as
soon as the water arrived in Bangladesh rural
water supply intervention (Hoque et al, 1996). In
the Buenos Aires study described above, households
diverted two-thirds of their savings from purchasing
water to purchasing food (Galiani, Gonzalez-
Rozada & Schargrodsky, 2008). e authors judged
it possible that improved child nutrition resulted
in both cases. is could have contributed to reduced
diarrhoea morbidity but would be difficult
to disentangle from the direct effect of increased
access to water. Particularly in Buenos Aires, the
reduction in diarrhoea, however it was produced,
would have had a markedly pro-poor bias since
these householders were among the most marginalised
of the city’s residents.
e fih impact pathway relates to the diffusion
of innovations. Interventions are implemented
in communities whose members share information
though social networks which oen reach into
neighbouring communities. In the Guatemalan
study discussed above (Torun, 1983), the proportion
of control households in which at least half of the
27 hygiene behaviours promoted were deemed
adequate increased 120%. is was much less
than the 560% increase in treatment households
but evidence of spontaneous communication
among villagers. is ‘contamination’ likely led
to an underestimation of the intervention’s impact
on diarrhoea, which was calculated as the difference
in morbidity between treatment and control
households. But rather than considering this solely
as an estimation problem, to be designed out or
corrected for statistically, it is important to ask
how people’s agency can be enlisted to enhance
the reach and sustainability of interventions.
e sixth and final impact pathway concerns
local institutions. e Waddington review and
most of the studies it draws on <strong>focus</strong> on individuals
and households. ey largely ignore the adaptive
capacity for self-governance of the communities
in which interventions are implemented. A few
studies however show how emergent and existing
institutions can influence the spread, adaptation
References
Galiani, S., Gonzalez-Rozada, M. and Schargrodsky, E. (2008).
Water expansions in shantytowns: Health and savings.
Economica 76: 607–22.
Hoque, B.A., Juncker, T., Sack, R., Ali, M. and Aziz, K. (1996).
Sustainability of a water, sanitation and hygiene education
project in rural Bangladesh: a 5-year follow-up. Bulletin of
the World Health Organization 74: 431.
Pattanayak S.K., Dickinson, K.L., Yang, J.C. et al. (2007).
Promoting latrine use: midline findings from a randomized
evaluation of a community mobilization campaign in
Bhadrak, Orissa. Working Paper 07-02. Durham NC: Research
Triangle Institute.
Pawson, R., Greenhalgh, T., Harvey, G., Walshe, K. 2005.
Realist review – a new method of systematic review
designed for complex policy interventions. Journal of
Health Services Research & Policy 10: 21–34.
Research
and retention of interventions. Pattanayak, Dickinson,
Yang et al (2007) describe the development
of local governance through norms against open
defecation in Odisha, India. Experiential learning
helps villagers to understand how they and their
children are contaminated by open defecation,
which oen triggers disgust. Social persuasion
adds to people’s motivation to progressively improve
their latrines or toilets. e poorest are oen
assisted from within or outside the community to
improve their facilities. Related processes are being
supported on a broader scale through Community-Led
Total Sanitation (CLTS), an approach now
being implemented in more than 50 countries.
Conclusions
is re-review provides an enlarged view of WASH
interventions and their contexts. ere is evidence
that other interventions, previous or concurrent,
sometimes influence the field in which the intervention
and the evaluation operate. Multiple impacts,
positive or negative, unforeseen by the intervention’s
designers, may be produced, affecting health and
livelihood, many of them created or shaped by
beneficiaries or by people beyond the intended
reach of the intervention. ese actions and effects
suggest ways in which investment in WASH can
better support health and livelihood. ey also
affect the Waddington review’s conclusions regarding
the impact of WASH interventions on diarrhoea,
suggesting that these need to be revisited.
Taking account of the limitations of this rereview
and the imperative for more joined-up
policy across sectors, the authors recommend
that donors and commissioning organisations
support one or possibly more SRs of literature on
the different and multiple impacts of WASH interventions
on health and livelihoods.
More broadly, this study contributes important
experience to the continuing debate on appropriate
methods to evaluate and synthesise evidence on
complex interventions. In building evidence, there
is an urgent need for studies that can take the
measure of operational situations as they exist.
Evaluation teams should have the skills and flexibility
to pursue evidence of other impact pathways
that emerges during research: too oen study authors
were le to speculate on an unexpected
result. Good research practice, such as ensuring
baseline data, would have helped to draw more
insights from many of the studies reviewed. Better
research costs more but a large price is now being
paid by not being able to make proper sense of
what happens in interventions.
Tonglet, R., Isu, K., Mpese, M., Dramaix, M. and Hennart, P.
(1992). Can improvements in water supply reduce childhood
diarrhoea? Health Policy and Planning 7: 260–8.
Torun, B. (1983). Environmental and educational
interventions against diarrhea in Guatemala. In: Chen LC,
Scrimshaw NS (eds). Diarrhea and Malnutrition: Interactions,
Mechanisms, and Interventions. New York: Plenum Press.
Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R.
2013. RAMESES publication standards: realist syntheses. BMC
Medicine 11: 21.
Waddington, H and Snilstveit, B. (2009). Effectiveness and
sustainability of water, sanitation, and hygiene interventions
in combating diarrhoea. Journal of Development
Effectiveness. Taylor & Francis. 1: 295–235.
World Health Organization (2010). UN-Water Global Annual
Assessment of Sanitation and Drinking-water (GLAAS 2010):
Targeting Resources for Better Results. Geneva: World Health
Organization.
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