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Contents Pathways Linking WASH and Nutrition Outcomes 1 Pathway 1: Reduction in Diarrheal Disease 2 Pathway 2: Improved Gut Health 3 Pathway 3: Reduction in Protozoa and Helminth Infections 4 Pathway 4: Reduction in Anemia 4 Pathway 5: Time and Cost Savings 4 Entry Points for Improved Nutritional Outcomes 5 Radically Improve Quality of Services 5 Converge Nutrition-Specific and Nutrition-Sensitive Programs for Vulnerable Populations 5 Focus on Demographic and Geographic Targeting and Inclusion 5 Adapt “Child-Centric” Water Supply and Sanitation Interventions 6 Emphasize Behavioral Change and Use Innovative Approaches to Ensure Sustainable Behavior Change 7 Mainstream WASH in Other Sector Programs 7 Guidance for Nutrition-Sensitive Monitoring and Evaluation 9 Rationale for Measuring the Suggested Nutrition-Sensitive Indicators 11 Access and Quality Indicators 11 Sanitation and Hygiene Behaviors 11 Institutional Strengthening 14 Monitoring and Evaluation 14 Measuring Health and Nutrition Outcomes 14 Notes 15 References 16 Box 1. Low-Cost, Low-Tech Options for Microbial Testing 12 Figure 1. Pathways Linking WASH to Nutrition Outcomes 2 Map 1. Sanitation and Stunting and Sanitation and Poverty Levels in Tanzania 6 Table 1. Nutrition-Sensitive Indicators for WSS Lending Operations 9 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene iii Pathways Linking WASH and Nutrition Outcomes T his document summarizes evidence and defecation by 30 points, led to ­ guidance on project design and results frame- taller children on average, who Evidence shows that work indicators for nutrition-sensitive water were less likely to be stunted inadequate WASH can impact supply, sanitation, and hygiene (WASH) operations compared to children in con- child nutritional status through and components of other sector and subsector proj- trol villages (Pickering et al. five key pathways. ects, including social protection, health, disaster risk 2015). Improvements in child management, and irrigation. height were noted even though the intervention did ­ ignificantly reduce diarrheal disease in children. not s Inadequate WASH can impact child nutritional status The authors posit that the program may have impacted through multiple pathways (figure 1). These include child height through other pathways, such as a reduc- (1)  fewer episodes of diarrheal disease; (2) improved tion in the incidence of intestinal worm infections or gut health; (3) reductions in protozoa and helminth improved gut health. infection; (4) reductions in anemia; and (5) time and cost savings associated with fetching water, caring for A CLTS intervention in Indonesia (Cameron, Olivia, sick household members, and seeking treatment. and Shah 2019) reduced the prevalence of roundworm infestation by 46 points among children in treatment This note presents evidence for the effects of WASH on ­ communities, compared to control communities. nutritional outcomes for each hypothesized pathway. However, there were no improvements in hemoglo- Only a handful of studies report the direct effects of bin levels, height or weight for children exposed to the WASH on nutritional outcomes. A systematic review and CLTS intervention. meta-analysis of WASH interventions on child nutri- tional outcomes (Dangour et al. 2013) a ­ nalyzed five clus- A quasi-experimental study in Maharashtra has ter randomized trials of WASH interventions (Du Preez, found large increases in child HAZ despite only mod- Mcguigan, and Conroy 2010; Du Preez et al. 2011; Luby est improvements in village sanitation, suggesting et  al. 2004, 2006; McGuigan et  al. 2011). The authors health effects may be largely driven by changes in have found a borderline statistically significant effect of open defecation, as opposed to infrastructure water quality and handwashing interventions on height- improvement (Hammer and Spears 2013). However, for-age Z-scores (HAZ) (mean difference, 0.08; 95 per- randomized studies of the Total Sanitation Campaign cent Confidence Interval 0.00 to 0.16) in children less in India (Clasen et al. 2014; Patil et al. 2014) and a than five years old. At the time of the review there was CLTS intervention in Tanzania (Briceño et al. 2017) insufficient experimental ­ evidence on water supply and have shown no evidence of effects on child nutrition sanitation to include in the meta-analysis. outcomes. Since the publication of the systematic review, sev- The econometric literature has consistently found eral experimental studies of the effect of sanitation associations between open defecation and child stunt- on child nutrition have been published, which have ing. For example, one study finds that open defeca- shown mixed results. A community-led total sanita- tion, which is exceptionally widespread in India, could tion (CLTS) intervention in Mali, which reduced open account for much or all of the excess stunting in India Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 1 FIGURE 1. Pathways Linking WASH to Nutrition Outcomes Vectors Pathways Interventions Outcomes Diarrhea Water supply Improved drinking water Fluids access and quality Gut health Fields Impact on Protozoa and Improved community sanitation Feces Flies Sanitation nutrition helminth infections coverage, no open defecation Fingers Anemia Fomites Improved handwashing Hygiene and environmental cleanliness Time spent fetching water and seeking treatment Note: WASH = water supply, sanitation, and hygiene. (Spears, Ghosh, and Cumming 2013). The authors diarrhea in Kenya or Zimbabwe but did in Bangladesh. suggest that open defecation is especially harmful in There are several hypotheses as to why the WASH areas of high population density (Hathi et al. 2017) interventions failed to improve child growth. The lack and is therefore a high-risk factor for stunting in India. of effect could be due to insufficient elimination of Other  econometric analyses have also shown that fecal contamination in the environment (Ercumen improvements in sanitation were responsible for at et al. 2018), especially the presence of animal feces; least part of the decline in rates of stunting in Nepal limited behavioral change among non-intervention (Headey and Hoddinott 2015) and Bangladesh (Headey limited attention to other vectors households; and ­ et al. 2015). of  fecal-oral pathogen transmission, such as child hand contamination and toys or objects handled by The WASH Benefits and the Sanitation Hygiene Infant children. Moreover, the intensity of hygiene promo- ­ Nutrition Efficacy (SHINE) trials in Kenya (Null et al. tion and other awareness raising measures may not 2018), Bangladesh (Luby et al. 2018), and Zimbabwe have been sufficient to sustainably change behavior. (Humphrey et al. 2019) were large (greater than 5,000 newborns each) and well-funded studies. These randomized controlled trials were the first to cluster-­ Pathway 1: Reduction in Diarrheal Disease test the individual and combined effects of water qual- The relative contribution of diarrhea to undernutrition is ity, sanitation, handwashing, and nutritional inter- somewhat unclear, because poor nutrition is also a cause ventions on child health and development. Study of diarrhea. However, there is good evidence that findings are consistent across the three sites. The repeated episodes of diarrhea and severity of diarrhea WASH interventions alone did not significantly in young children are associated with growth stunting nutrition outcomes. The nutrition improve child ­ (Checkley et al. 2008; Ferdous et al. 2013; Moore et al. intervention—independently and when combined 2010). with the WASH intervention—increased child HAZ. However, there was no additional benefit for HAZ There is vast literature showing that poor WASH condi- from the combined intervention when compared tions such as fecal contamination of the household with the nutrition only or WASH only intervention. In environment (Curtis, Cairncross, and Yonli 2000; addition, the WASH intervention did not reduce Marquis et al. 1990), soil contaminated with human 2 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene and animal feces (Curtis et al. 2000; Pickering and correlate with sharing of sanitation facilities and poor Davis 2012), and unsafe disposal of infant and child child health (Heijnen et al. 2014). feces contribute significantly to diarrheal disease epi- sodes (Bawankule et al. 2017; Cronin et al. 2016; Mara Pathway 2: Improved Gut Health et al. 2010). Water supply and sanitation interventions Repeated exposure to pathogens found in feces is one are associated with lower risk of diarrhea and better of the primary contributors to environmental enteric nutrition outcomes (Checkley et al. 2004; Esrey 1996; dysfunction (EED), which is characterized by inflam- Fink, Günther, and Hill 2011). Meta-analysis of inter- mation and physical deformation of the small intestine vention studies shows (1) handwashing with soap (Prendergast and Kelly 2012). EED inhibits the absorp- reduces diarrhea by 30 percent compared to no inter- tion and retention of essential nutrients, which vention; (2) sanitation interventions reduce diarrhea researchers hypothesize is a major cause of child stunt- by 25 percent compared to no intervention (with evi- ing (Gilmartin and Petri 2015; Humphrey 2009). dence for higher reduction at 45 percent when cover- age is above 75 percent); and (3) piped water supply of Household environments in low-income settings are higher quality and continuous availability to premises highly contaminated with fecal matter from poor qual- reduces diarrhea by 75 percent and 36 percent, respec- ity sanitation and open defecation practices. Freely tively, compared to unimproved drinking water (Wolf roaming animals are common in such settings, espe- et al. 2018). cially where small-holder poultry farming is the norm (Harvey et al. 2003; Marquis et al. 1990; Ngure et al. There is wide variation in risk reduction for different 2013), contributing to high concentrations of animal service levels: high-quality piped water reduces diar- feces in the environment. rhea by 75 percent, but water filtered at point of use (POU) with safe storage achieves a risk reduction of Both humans and animals tread on feces in the open, 61 percent. Similarly, sewerage connections are associ- bringing pathogens into the domestic environment ated with larger diarrhea risk reduction of 40 percent (Curtis et al. 2000) where infants and young children compared to a 16 percent risk reduction from improved crawl, explore, play, and feed. Flies serve as another vec- household sanitation (Wolf et al. 2018). tor carrying pathogens from one place to another, espe- cially onto food. Handwashing with soap is poorly Sanitation facilities shared between households are practiced in these settings (Curtis et al. 2000), so it does associated with increased odds of diarrheal disease not prevent the spread and ingestion of fecal bacteria. compared to individual household latrines in a meta-analysis of 12 studies (Heijnen et al. 2014) report- Recent research has focused on testing the hypothesis ing on diarrhea, although the analysis does not distin- that EED caused by poor WASH (Crane, Jones, and guish between types of shared facilities, which could Berkley 2015) is a major cause of child stunting, with include a household latrine shared with another fam- evidence pointing to the link between intestinal and ily, latrines shared by more than one household, or systematic inflammation and stunting (Harper et al. community latrines. Moreover, 22 studies conducted 2018). Observational research shows associations in 21 countries show increased risk of adverse health between household environmental cleanliness, such outcomes associated with shared sanitation compared as access to water supply and sanitation infrastructure, to individual household latrines. Few of these studies, biomarkers for environmental enteropathy, and child however, report on factors—other than the type of san- HAZ and WAZ (Lin et al. 2013). However, intervention itation facilities—that could be important confounders studies of handwashing (Langford, Lunn, and Panter- or effect modifiers, such as poverty, and that may Brick 2011) and results from WASH-Benefits trials in Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 3 Kenya (Null et al. 2018) and Bangladesh (Luby et al. common nutritional deficiency in the world and highly 2018) have not led to lower mucosal damage or chronic prevalent in low- and middle-income countries (LMICs). infections nor have they slowed growth faltering. Blood loss and inflammation due to WASH-related ­ infections, including malaria, acute respiratory infec- tions, diarrhea, and hookworm infection (Stoltzfus et al. Pathway 3: Reduction in Protozoa and 1996), are a major cause of anemia (Weiss and Goodnough Helminth Infections 2005). Without treatment, anemia can lead to chronic Protozoa and helminth infections are transmitted conditions that include poor fetal development, delayed through soil (soil-transmitted helminthiasis, STH) cognitive development, higher risk of infection, fatigue, and water (schistosomiasis) contaminated with feces. weakness, dizziness, and drowsiness. Dietary interven- These infections cause poor appetite, nutritional defi- tions that include iron supplementation have resolved ciencies, and anemia and exacerbate malnutrition fewer than half of the burden of childhood anemia glob- (O’Lorcain and Holland 2000; Stephenson 1987; ally (Stoltzfus, Mullany, and Black 2002). A trial of WASH Stephenson, Latham, and Ottesen 2000; Stoltzfus improvements in Bangladesh has reported a protective et al. 2004). Studies have shown giardia and helminth effect on the risk of anemia, but a similar trial in Kenya infections to be associated with stunting (Crompton has not found any added effect of the WASH interven- and Nesheim 2002; Heimer et al. 2015; Simsek et al. tions on anemia when compared with the nutrition-­ 2004). specific intervention (Stewart et al. 2019). Where helminths are highly prevalent, deworming medication is administered as preventative chemo- Pathway 5: Time and Cost Savings therapy through organized campaigns. This is a cheap Reducing the time that caregivers spend fetching water and effective strategy to reduce infections, but cannot has been shown to reduce diarrhea and improve nutri- prevent future reinfection, especially in places with tional outcomes in children under age five (Pickering poor sanitation. Therefore, sanitation promotion is and Davis 2012). The exact mechanism is not clear, often recommended as a complementary strategy to although better access to water may enable improved deworming and health education. Meta-analysis hygiene practices (Aiello et al. 2008; Motarjemi et al. shows a protective effect between any sanitation (pres- 1993) and allow more time for caregiving (Burger and ence or use) compared to no sanitation and the risk of Esrey 1995; Cairncross and Cliff 1987; Diaz et al. 1995; soil-transmitted helminths (Barreto et al. 2010; Miller and Urdinola 2010) or income-generating activi- Freeman et al. 2017; Moraes et al. 2004; Ziegelbauer ties (Koolwal and Van de Walle 2013). About 44 percent et  al. 2012) and giardia infections (Goto et al. 2009). of the world’s population must leave their homes to The WASH-Benefits trial in Bangladesh has found that fetch water for drinking and other domestic uses (WHO individual handwashing and hygienic sanitation inter- and UNICEF 2010). The high costs associated with ventions significantly reduced childhood giardia infec- accessing improved WASH services and the time and tions (Lin et al. 2018). cost of treating WASH-related illness could crowd out household expenditures for other nutrition-related Pathway 4: Reduction in Anemia inputs such as nutrient-dense food. In addition, house- Anemia is a blood disorder that most commonly results holds far from a water source may face barriers to from insufficient dietary intake and absorption of iron. home gardening and other income generating activi- Iron can be absorbed through diet, but malnutrition can ties that have a direct or indirect effect on improving inhibit its absorption. Iron deficiency anemia is the most nutrition (Moriarty et al. 2003). 4 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene Entry Points for Improved Nutritional Outcomes T he current body of evidence on the links interventions alone can- WASH ­ between WASH and nutrition provides not address other deprivations Reductions in stunting are more important clues as to what nutrition sensitive ­ faced by children living in pov- likely to materialize when the enhancements are needed to achieve greater impacts erty, such as low rates of breast- multiple contributing factors— on early child nutrition. The following six principles feeding, low-caloric intake, and food security, access to health aim to address some of the limitations that are found consumption of a diet low in care, child care practices, and with conventional WASH interventions. diversity. access to water supply and sanitation—are adequately Studies show that reductions in Radically Improve Quality of Services addressed for a child. stunting are more likely to mate- The Sustainable Development Goals (SDGs) have rialize when the multiple con- raised the quality standard to safely managed water tributing factors—food security, access to health care, supply and sanitation. The shift from addressing just child care practices, and access to water supply and san- access to quality, equitable, and sustainable services is itation—are adequately addressed for a child. For exam- an important enhancement that has the potential to ple, analysis across 33 countries in Sub-Saharan Africa improve child health and nutrition impacts of WASH shows the prevalence of stunting for children with services. At present, what may be defined as improved simultaneous access to adequate levels of key water supply and sanitation services are the source of nutrition  drivers is significantly lower than the preva- ­ disease, rather than protection from disease. For exam- lence of stunting for children who do not have access to ple, water samples tested across sources in five these drivers (World Bank 2018). Moreover, there is evi- countries under the World Bank WASH Poverty ­ dence that multisectoral interventions work. An obser- Diagnostic (2017b) have had E. coli contamination from vational before-after study of multisectoral interventions 48 percent to nearly 100 percent of the time, and there in nine sub-Saharan African countries has documented have been no differences found comparing piped to large reductions in childhood stunting prevalence in other improved water sources, such as protected wells. program areas, while levels of stunting at the national level remained unchanged (Remans et al. 2011). A similar shift toward quality of service has accompa- nied the health SDG goal of universal health coverage, which encompasses equity, quality, and financial risk Focus on Demographic and Geographic protection. This is based on the recognition that hav- Targeting and Inclusion ing access to health care has not necessarily translated While WASH interventions are typically delivered at into better health outcomes. the community level, there is justification for targeting certain behavioral interventions to pregnant women Converge Nutrition-Specific and and households with children under two years of age Nutrition-Sensitive Programs for (the first 1,000 days of a child’s life). These include Vulnerable Populations interventions that address infant food hygiene and Available evidence suggests that improvements in containment of animal feces. Diarrhea risk increases water supply and sanitation need to be combined with during the infant weaning period in low-income set- other nutrition-specific and nutrition-sensitive inter- tings, and child growth often falters after the initiation ventions to reduce child stunting (World Bank 2017b). of weaning foods (Motarjemi et al. 1993). Therefore, Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 5 contaminated weaning foods may be a more important water supply is low and stunting levels are high. contributor to diarrheal disease than contaminated These maps have been used to engage in a dialogue drinking water in these settings (Lanata 2003). Animal with the Tanzanian government to identify target feces remain a common source of contamination in areas for WASH investments under the Rural Water low-income settings, even in areas of high sanitation Supply and Sanitation Program-for-Results coverage and low rates of open defecation. Crawling operation. infants are frequently exposed to these contaminants in the household environment as they practice explor- Adapt “Child-Centric” Water Supply and atory and mouthing behaviors. Sanitation Interventions Geographic inclusion is another approach to target Conventional WASH interventions may still bypass resources to areas that are more likely to realize some of the dominant fecal contamination pathways health and nutrition benefits from improvements in that affect small children. An emerging approach WASH. Geospatial mapping can identify target areas known as “baby WASH” or “child-centered WASH” where undernutrition and underlying deprivations, includes food hygiene, clean play environment, man- such as lack of access to water supply and sanita- agement of animal and child feces, and infant and tion, are high. In Tanzania, the WASH Poverty child handwashing. It has been proposed to address Diagnostic (2017a) produced maps (map 1, panels a these neglected pathways (Ngure et al. 2014). In some and b) to illustrate the cross-section of sanitation, contexts, it may be more efficient to deliver these supply, and stunting. Areas marked in red water ­ child-focused interventions through community highlight where access to improved sanitation or health and other social engagement platforms that MAP 1. Sanitation and Stunting and Sanitation and Poverty Levels in Tanzania a. Sanitation and stunting b. Water access and stunting Cross-mapping of stunting Cross-mapping of stunting versus versus WASH: population using WASH: population using improved sanition (%) improved water (%) (dry season) Stunting WASH Stunting WASH prevalence indicator prevalence indicator Low Low Low Low Low High Low High High Low High Low High High High High Admin boundaries Admin boundaries 0 20 40 80 Miles 0 20 40 80 Miles Districts Districts Source: World Bank 2017a. 6 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene frequently interface with caregivers of young chil- behavior change campaigns dren. Coordination with community agriculture and (Coville and Orozco 2014; Baby WASH goes beyond livelihoods programs is also important, because these Kahneman and Tversky 1979). conventional WASH sometimes introduce livestock, which could result in interventions to address Analysis shows that behavior animal feces contaminating the living environment. food hygiene, clean play change messages delivered at Baby WASH interventions could include the following: environment, management high frequency and intensity of child and animal feces, and • Sweeping and washing of child’s play environment, are more likely to lead to infant and child handwashing. including play objects, to ensure it is free of child changes in behavior that are and animal feces maintained over time; how- • Fencing off or caging poultry and livestock so they ever, this level of intensity is not practical in many cannot contaminate the household environment low-resource settings. More effective behavior change • Washing infant’s and child’s hands with soap before will benefit from the use of disruptive technologies; unconventional media; and information, communi- eating or breastfeeding cation and technology (ICT) tools, techniques, and • Using clean and treated or boiled drinking water for devices that can deliver messages more effectively preparation of weaning foods and that can cater to known behavioral biases. • Using cups, not bottles, since the latter can harbor bacteria Mainstream WASH in Other Sector Emphasize Behavioral Change and Use Programs Innovative Approaches to Ensure Social protection, health, nutrition, and livelihoods Sustainable Behavior Change programs provide a community-based platform for Until universal access to safely managed water sup- delivery of nutrition-related services and may be suit- ply and sanitation services is achieved, human able for integration of WASH interventions. These behavior will continue to be critical for early child programs sometimes target services to households health impacts. However, behavioral change is hard that have pregnant women and young children. They to achieve, let alone sustain. Experience shows that can provide a suite of services to beneficiaries, while just teaching people about behaviors such as hand- reducing the costs associated with parallel or conver- washing, drinking water treatment, and toilet use is gence programming. For example, conditional cash necessary, but it is not sufficient, because knowl- transfer programs use targeting systems that enable edge of these behaviors is already high in many both geographic and demographic (first 1,000 days contexts. of  a child’s life) targeting of nutrition-specific and -sensitive services without incurring additional costs. ­ Behavior change campaigns need to first appeal to the WASH integration may be more practical in some desires and behavioral biases of the target population. rural and hard-to-reach areas where infrastructure Health benefits, for example, are seldom a strong moti- solutions are not feasible or cost-effective. Services vator for changing behavior—people respond more that can address WASH behaviors and practices strongly to emotional appeals such as a desire to be include the following: clean and modern or appeals to one’s pride or dignity. Behavioral biases often dictate people’s decision • Social mobilization to construct and use household making, more so than rational thinking, so under- ­ toilets, or to construct small-scale community water standing these may help to design more effective supply systems Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 7 • Parental counseling and behavior change commu- WASH integration has limitations because the nication around household sanitation and hygiene programs may not address institutional capacity ­ needed to sustain service delivery. For example, with- • Provision of simple consumables such as clean birth out adequate operational and maintenance support to kits, soap, and water purification tablets during keep community water systems functioning, they can household or community meetings, or during pre- break down, leaving households with no option but to natal and well-child visits revert to an unimproved water source. Some programs • Training of health and education staff on sanitation rely heavily on behavioral change, which is difficult to and hygiene behaviors and practices achieve and sustain. 8 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene Guidance for Nutrition-Sensitive Monitoring and Evaluation B uilding the evidence base on the effectiveness lending operations. These indicators can also be used nutrition-sensitive WASH inter- and impact of ­ for WASH components of projects in other sectors, such ventions requires enhancing existing monitoring as health sector projects. The selected indicators would and evaluation efforts. Table 1 presents a set of results need to be adapted to the project context, including data sensitive framework indicators to support nutrition-­ availability, project components, and monitoring and WASH monitoring in water supply and sanitation (WSS) evaluation capacity. TABLE 1. Nutrition-Sensitive Indicators for WSS Lending Operations Additional key results indicators for Qualifies as Key results indicators for WSS operations Data source and calculation nutrition-sensitive WSS operations gender indicator Access/quality • People provided with access to improved Beneficiary households with children Project-level data collected water sources**(number) under 5 (number) by implementing agencies • People provided with access to improved or MIS, combined with sanitation**(number) administrative/population survey data • Number of improved latrines constructed • Number of communities/households with access to SLWM services Percentage of water quality tests that meet Percentage of source or stored water Project level data collected by required standards quality tests that meet required standards ­ implementing agencies or MIS Number of schools and health centers with Number of health centers providing Project-level data collected ✓ improved WSS facilities antenatal/maternal care with improved ­ by implementing agencies WSS facilities or MIS Hygiene behavior/open defecation Number of communities/villages certified Number of children under 5 benefiting Using administrative data ✓ as ODF from living in villages certified as ODF on population of under-5 children (birth rate), estimate number of children in villages certified as ODF None Proportion of households practicing Baseline and follow-up safe disposal of child and animal feces household surveys • Behavior change campaign designed and • Number of frontline workers who have Project-level data collected implemented received nutrition-sensitive WASH by implementing agencies • Percentage of target audience reached behavior change communication training through behavior change awareness campaign • Number of behavior change • People trained to improve hygiene behavior communication plans that incorporate or sanitation practices child-centered WASH behavior change Schools/health centers with handwashing Number of health centers providing Project-level data collected ✓ facilities antenatal/maternal care with hand- by implementing agencies washing facilities or MIS Percentage of target audience that practice Percentage of caregivers of children Baseline and follow-up ✓ hygiene behavior (e.g., handwashing with under 5 who are washing hands with household (sticker diary soap, use of latrines) at key times (e.g., after soap after using latrine method recommended)a defecation) table continues next page Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 9 TABLE 1. continued Additional key results indicators for Qualifies as Key results indicators for WSS operations Data source and calculation nutrition-sensitive WSS operations gender indicator Institutional strengthening Staff trained in O&M of schemes Number of water scheme opera- Project-level data collected tors (e.g., district officers) receiving by implementing agencies environmental health training Monitoring and evaluation Number of communities/villages maintaining Number of communities/villag- Project-level data collected information on WSS services/MIS es in project areas that use an MIS through MIS harmonized with health MIS None Number of communities/villages in Project-level data collected project areas participating in surveillance by implementing agencies system for safe drinking water Note: Indicators are indicative and may require modification to match the context of a particular project. MIS = management information system; ODF = open defecation free; O&M = operations and maintenance; SLWM = solid and liquid waste management; WASH = water supply, sanitation, and hygiene; WSS = water supply and sanitation. ­ a. The sticker diary is a survey methodology developed by Unilever and the London School of Hygiene and Tropical Medicine in which respondents are given a set of pictorial representations of common daily activities and are asked to create a “diary” of daily behaviors under the guidance of a trained ­ enumerator. The method has been successfully applied in India and Vietnam, and has shown to reduce over-reporting of handwashing behaviors, while being less costly than traditional observation methods. 10 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene Rationale for Measuring the Suggested Nutrition-Sensitive Indicators Access and Quality Indicators using random sampling. Box 1 mentions the key ­ characteristics of a water quality testing kit and the A key pathway to improved nutrition is through improve- three approaches employed in testing water quality. ments in service quality, including the quality of infra- Evidence shows that water collected outside the home structure. The SDGs define an ambition for WASH service is frequently recontaminated in the home due to poor delivery that goes beyond building pipes and toilets to storage methods and unsafe access practices (e.g., providing services that effectively reduce environmental unsanitary storage vessels or those with no covers and fecal contamination, including water quality, continuity dipping utensils) (Clasen and Bastable 2003; Wright, of service, septage and fecal sludge management, and Gundry, and Conroy 2004). Beneficiary and household hygiene practices. Moreover, the SDGs emphasize inclu- surveys can include water quality testing. This is usu- sion of vulnerable populations, women, and children, ally done by asking the respondent to fetch a glass of which is critical for meeting nutrition objectives. The water usually given to the child under five in the home ­ following indicators reflect these aspects of the SDGs. and testing it for quality. Access to Improved Water Sources and Health Centers Providing Antenatal and Improved Sanitation Facilities for Beneficiary Maternal Care with Improved Water and Households with Children under Five Sanitation Facilities Improvements in infrastructure are a critical factor for Provision of basic water supply1 and sanitation2 in the nutritional outcomes. Higher levels of service show health care facility premises is critical to ensuring greater risk reduction for diarrheal disease in meta-­ maternal, newborn, and child health. Improved WASH analysis of intervention studies (Wolf et al. 2018). facilities in health settings enhances quality of care, Monitoring access among children under five can demon- which encourages mothers to seek prenatal care and strate the reach of WSS service delivery for a priority deliver in facilities rather than at home, which are population for achieving stunting reduction targets. ­ important for reducing maternal and newborn deaths (Russo et al. 2012). A systematic review of WASH and Source and Stored Water Quality Tests quality of care shows associations between adequate Dangour et al. (2013) have found a statistically signifi- WASH services in health care facilities and care-­ cant effect of water quality on HAZ scores in children seeking and patient satisfaction, with positive impact less than five years old, demonstrating the importance on health outcomes (Bouzid and Hunter 2018). of water quality for child outcomes. At a minimum, nutrition-sensitive water supply interventions should test water quality at the source—at the water utility or Sanitation and Hygiene Behaviors community-based water system—routinely and report Hygiene behaviors are a critical link between improve- these results through a MIS. If feasible in the project ments in infrastructure and health and nutrition out- context, water quality should be tested at the comes. This is particularly important in places with point-of-collection (e.g., standpipe) and point-of-use lower quality services. Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 11 BOX 1. Low-Cost, Low-Tech Options for Microbial Testing [Water quality testing kits] should be portable, low-skill, self-contained, lab-free, and electricity-free. It should be available globally at a cost of less than $0.10 (USD) per test, and it should be easy to interface with data reporting and communications technologies. It should also be integrated into education programs to mobilize stakeholders. To this we might add that (semi)quantitative results should be available quickly, without a 12 (24, 48, etc.) hour incubation period. —Dr. Mark Sobsey, University of North Carolina at Chapel Hill Water quality tests take one of three approaches: Presence-absence (P-A). P-A tests change color to show whether microbial contamination has been detected. They don’t provide quantitative information about microbial water quality. Test kits are comparatively inexpen- sive, but often involve adding a powdered nutrient mixture and an incubation period of 24 hours for organ- isms to grow. P-A tests are suitable for screening in situations when microbial contamination is not expected (e.g., deep groundwater). Most probable number (MPN). MPN tests are semi-quantitative. Several samples of the same water are tested in tubes, plastic bags, or small plastic plates with multiple wells. The user adds a nutrient solution (“culture media”) and waits 12–48 hours for organisms to grow before counting the number of positive samples, indicated by a color change. The user then converts that number of positives to a statistical estimate of bacterial concen- tration, as per the instructions for the particular test. Membrane filtration. Membrane-based tests are the most quantitatively accurate. In general, a 100-milliliter water sample is forced or vacuumed through a small, round filter paper (the membrane) using a little hand pump. All the bacteria in the sample are caught on the filter as the water passes through. The filter is then incu- bated with some sort of culture media. Each bacterium caught on the filter will multiply into a little colony. After the incubation, the user counts the colonies—possibly with the aid of a magnifying glass—to determine how many “colony-forming-units” were present in the original sample. Due to the filtration step, membrane-based tests are more difficult when water samples contain a lot of suspended material, and they can take time. Source: Mistry and Lawson 2018. Children under Five Benefiting from Open of stunting (Larsen et al. 2017; Pickering et al. 2015). Defecation Free Monitoring open defecation practices rather than Open defecation, particularly in areas of high popula- counting number of toilets built has been a key shift in tion density (Hathi et al. 2017), places children at high approach to rural sanitation (Verma and Sengupta 2018). risk of illness, and there is mounting evidence that high This indicator provides an estimate of the number of levels of coverage of sanitation in a community are asso- children benefiting from improved sanitary conditions ciated with lower probability of disease and lower rates and is a proxy for better health outcomes. 12 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene Households Practicing Safe Disposal of Child and WASH focuses on interrupting exposure pathways Animal Feces that are most strongly associated with enteric infec- The domestic environment can become contaminated tions known to cause malnutrition. This includes with feces even when improved latrines are available. ensuring the cleanliness of a child’s play environment Young children often practice open defecation when and play objects by practicing safe disposal of child they are too young to be easily trained to use the latrine and animal feces, separation of livestock and domes- or due to fears of falling into the pit. If these feces are tic animals from the main housing compound, wash- left in the open, they can contaminate the environ- ing infant’s and child’s hands with soap before eating ment. Free-roaming animals such as chickens are com- or breastfeeding, using only clean or treated drinking mon in low-income settings, and their feces is difficult water for preparation of liquid and solid foods for to manage. It is estimated that approximately one- infants and young children, and use of child cups (not third of deaths among children under five years is due bottles because they can harbor bacteria). Behavior to pathogens found in animal feces alone (Wang et al. change communication plans should explicitly 2015). This indicator is a proxy for fecal contamination address nutrition-sensitive behaviors and identify in the environment. delivery platforms to increase effectiveness and effi- ciency. For example, delivery of child-focused inter- Frontline Workers Who Have Received Nutrition- ventions may be more effective through health Sensitive Behavior Change Communication workers. Training Frontline health communicators are essential for Health Centers Providing Antenatal and Maternal improving child nutrition (Sunguya et al. 2013). Many Care with Handwashing Facilities countries and programs train these agents to commu- Proper hand hygiene is the most effective way to nicate social and behavior change messages at the reduce risk of infection at the lowest cost (Larson 1988; community level, either through household visits, in Mathur 2011). Evidence shows that simple behaviors group settings, or in health and educational institu- such as handwashing with soap by birth attendants tions. Nutrition-sensitive behavior change messages can dramatically reduce neonatal deaths (Rhee et al. that address the child-specific pathways of fecal trans- 2008). Basic hand hygiene is defined under the SDGs as mission (such as handwashing with soap for caregivers availability of (1) either alcohol hand rub or water and of young children, child handwashing, use of clean soap at points of care, and (2) handwashing facilities utensils for feeding, and use of boiled water for prepa- with water and soap at the toilets (JMP 2018). ration of weaning foods) can enhance traditional Pregnancy provides a window of opportunity to instill WASH behavior change messaging by better targeting new habits in mothers that will benefit the health of the fecal transmission pathways that pose the most their children. danger to young children and infants. Caregivers of Children under Five Washing Hands Behavior Change Communication Plans that with Soap after Using the Latrine Incorporate Child-Centered WASH Behavior Maternal caregiver handwashing with soap reduces Change the risk of diarrhea by 40 percent (Freeman et al. Traditional WASH behavior change messages may 2014) and is therefore a critical behavior for improv- bypass some of the dominant fecal contamination ing child health. There are innovative methods for pathways that affect small children. Child-centered measuring handwashing that reduce cost and bias. Nutrition-Sensitive Water Supply, Sanitation, and Hygiene 13 The sticker diary is a methodology developed by Number of Communities or Villages in Project Unilever and the London School of Hygiene and Areas that Use an MIS System Harmonized with Tropical Medicine whereby respondents are given Health MIS a set of pictorial representations of common daily Harmonization of MIS across sectors refers to the use activities and are asked to create a “diary” of daily of consistent indicator definitions and coordinated behaviors under the guidance of a trained enumer- data collection. This improves the efficiency of moni- ator. The method, applied in India and Vietnam, toring and enhances cross-sectoral coordination. In handwashing has shown to reduce overreporting of ­ the case of WASH and nutrition, this can enable behaviors, while being less costly than traditional cross-tabulation of access indicators with select health observation methods. The percentage of care- and nutrition outcomes. givers of children under five washing hands with soap after using the latrine can be estimated by Number of Communities or Villages in Project dividing the number of respondents who report Areas Participating in Surveillance System for washing  hands  with soap by the total number of Safe Drinking Water respondents. A surveillance system provides routine monitoring of water quality at specific locations throughout the ­system. Institutional Strengthening ­ ervice pro- It can be used to document the quality of s vided and enable rapid response to health risks. Institutional actors should be held accountable for ensuring the quality and functionality of WASH ­ services, which in turn improves health outcomes Measuring Health and Nutrition Outcomes among the population using those services. Including health outcomes in the project results frame- work raises issues of attribution and cost. These challenges Number of Water Scheme Operators Receiving are outlined here for various outcome measures. It  is Environmental Health Training uncommon even for health operations to measure these Environmental health training should be a core com- outcomes. For multisectoral projects that adopt a conver- ponent of capacity building for water scheme opera- gence approach, it may be appropriate to measure health tors (e.g., district officers). It should cover issues and nutrition outcomes at the program or portfolio level, around source water quality and associated health so projects share in the accountability for health and nutri- risks of agricultural or industrial run-off; groundwater tion outcomes and no single project claims attribution. contamination; drinking water treatment to prevent Diarrheal disease. Prevalence of diarrhea is relatively biological or chemical contamination; and health risks easy to collect, but it is highly variable and requires associated with low water pressure, leaks, broken large sample sizes to estimate with precision. Self- or pipes, and sedimentation. caregiver-reported diarrhea can be biased downward due to placebo effects, social desirability bias, and Monitoring and Evaluation recall attenuation bias, and therefore may show impact WASH sector monitoring and surveillance systems where there is none. Moreover, diarrhea is caused by that are harmonized with health management infor- multiple factors, and without an appropriate research mation systems can improve coordination across design to attribute causality, data may not be suffi- these sectors for better planning and rapid response ciently specific to demonstrate impact. Measures of to health risks. diarrhea include (1) incidence of diarrhea in previous 14 Nutrition-Sensitive Water Supply, Sanitation, and Hygiene seven days (or two weeks) for children under five or for finger prick, specialized equipment, and training, which adults; (2) symptom-based recall of watery stools and may not be practical for most projects. Moreover, anemia three or more stools per day, or blood in stool. has many causes that are not affected by WASH. Anthropometrics. Child anthropometrics are objective Helminth and protozoa infection. The presence of these measures of nutrition, but are costly to measure because parasites can be measured in stool samples of children. they require specialized equipment and well-trained Stool is collected and tested in a laboratory. These staff. Moreover, they have low specificity because growth measures have high specificity because they are spread can be influenced by many factors. Some growth mea- through contaminated food and water. However, stool sures, such as height-for-age, are best measured in the sample testing can be costly and logistically long term, which is not always practical for typical proj- challenging. ect and evaluation time frames. Systematic administra- Enteric infection biomarkers. New methods to predict tive data on height and weight are uncommon and long-term nutritional outcomes using stool samples are population-level data are typically collected only every being developed. Noninvasive saliva samples can be five years. Measures include height- and length-for-age, tested for the presence of antibodies to common diar- weight-for-age, and head and arm circumference. rheal disease pathogens. Further research is needed to Stunting. Defined as the share of the population of establish the validity and reliability of these measures. children under five whose HAZ and length-for-age ­ Z-score (LAZ) is less than 2 standard deviations below the Notes median of the reference population. 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