WASH’ Nutrition

1. OPERATIONAL RESEARCH
Beyond the impact on disease reduction, a growing base of evidence indicates that WASH environment can be critical in
shaping children’s nutritional outcomes. 213 WASH interventions can positively impact stunting incidence rates, with the
highest effect on children under the age of 2. 214 Peruvian 2-years-old children with the worst water source, water storage,
and sanitation conditions were 1.0 cm shorter than children with the best conditions. 215 Analysis of cross-sectional data from
65 countries reports that open defecation explains 54% of international variation in children’s height. This link is even stronger
when population density is high. 216 This suggests that India’s widespread open defecation and high population density place
children at increased risk of stunting and may help explain the “Asian enigma”- despite increased economic growth, children in
Asia are shorter on average than those in Africa, who are poorer. 217 While the evidence regarding the consequences of poor
WASH conditions (especially exposure to poor sanitation) on low height for age - stunting is particularly strong, the effects
of WASH interventions on low weight for height – wasting are still to be explored. More data is needed to demonstrate how
and in which ways specific WASH mechanisms affect nutrition outcomes and determine which implementation modalities are
most likely to lead to strong and sustained impact. 218 Ongoing trials and large intervention studies such as the ACF Ouadinut
study 219 in Chad, Sanitation Hygiene Infant Nutrition Efficacy (SHINE) 220 in Zimbabwe and WASH benefits 221 in Bangladesh and
Kenya should greatly support the evidence base in this area.
BOX 19: Effectiveness of adding a Household WASH component to a routine
outpatient programme of Severe Acute Malnutrition
The WASH’Nutrition strategy is largely promoted, at least in the Sahel region, and includes 5 pillars, of which, the provision
of a WASH minimum package at health level and at household level. One of the activities under this pillar is the delivery of
a household WASH kit to the caretaker of the child upon admission for severe acute malnutrition (SAM) at health centre,
which is designed to protect children against new episodes of diarrhea and aiming at improving nutritional outcomes.
However, there is no evidence on its effectiveness yet.
In the context of ambulatory nutritional rehabilitation of SAM children, we hypothesize that improving water quality and
hygiene-related care practices at household level would decrease incidence of WASH-related infections, such as diarrhea,
nematode and environmental enteropathy. As such, it would improve weight gain, recovery, and decrease risk of relapse after
successful discharge. In order to test these hypotheses, Action Contre la Faim implemented in 2016 a cluster randomized
controlled trial in Mao and Mondo health districts, Kanem region in Chad, embedded into a routine nutritional ambulatory
programme and comparing two arms: 1) control group: routine nutritional ambulatory programme 2) Intervention group:
routine nutritional ambulatory programme + “household WASH kit”. The “household WASH kit” includes water container,
water disinfection consumables, soap, cup and hygiene promotion leaflet provided at beginning of SAM treatment. Both
groups received sessions of hygiene promotion provided weekly at health centre. 1600 children, aged between 6 and 59
months, admitted to 20 health centres for non-complicated SAM, were included into the study and followed up to discharge.
Successfully discharged children were also checked at 2 and 6 months after discharge. Primary evaluation outcomes are
cured and relapsed proportions. Secondary outcomes include length of stay, weight gain, morbidity outcomes and home
water quality and hygiene practices.
This project is conducted within a partnership that includes Action Contre la Faim- France, the Institute of Tropical Medicine
in Antwerp, Belgium, and the Sahel Association of applied research for sustainable development (ASRADD) in Chad.
Financial support is provided by ACF and the British Department for International Development (DFID). Results will be
released soon (early 2017).
Source: ACF, Institute of Tropical Medicine, ASRADD The OUADINUT study – Kanem region, Chad
In spite of existing uncertainties, there has been a common agreement among humanitarian actors, including donors, on
sufficiency of evidence to justify and support the integration of nutrition and WASH interventions.
213 - Dangour et al, 2013; Ikeda et al, 2013.
214 - Dangour et al, 2013.
215 - Checkley, W., R.H. Gilman, R.E. Black, et al (2004) “Effect of water and sanitation on childhood health in a poor Peruvian peri-urban community”.
216 - Spears D & the World Bank (2013) “How much international variation in child height sanitation can explain?”.
217 - SHARE/LSHTM/WaterAid (2015) “Undernutrition and water, sanitation and hygiene”.
218 - WASHPlus (2015) “Integrating WASH and Nutrition – learning brief”.
219 - https://clinicaltrials.gov/ct2/show/NCT02486523
220 - https://clinicaltrials.gov/ct2/show/NCT01824940
221 - http://www.washbenefits.net/
WASH’Nutrition
A practical guidebook
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