WASH’ NutritioN - ACF-USA · 3 WAsh’nutrition A practical guidebook WAsh’nutrition A...

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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

5WAshnutrition


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


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([email protected]),PublicHealthconsultant-ExpertiseandAdvocacyDepartment,WASHsector,ACF-FranceDesign:ClineBeuvinPhoto on cover PAge: B.Stevens/i-ImagesforActionAgainstHunger

ActionContrelaFaim2017,14/16BoulevarddeDouaumont-CS80060-75854ParisCedex17-France

Asoftcopyoftheguidebookmaybedownloadedat:www.actioncontrelafaim.org

7WAshnutrition


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


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


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


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


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


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


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


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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


the

bA

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of

un

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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


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


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

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