The conceptual framework of under-nutrition

  • RLO
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The conceptual framework of under-nutrition

What are the main causes of under-nutrition?

The determinants of under-nutrition are complex and nutritional status is dependent on a wide range of diverse and interconnected factors. At the most immediate level, under-nutrition is the outcome of inadequate dietary intake and repeated infectious diseases. The underlying causes include food insecurity, inappropriate care practices, poor health sector performance and unsafe environment including access to water, sanitation and hygiene. All these factors result in increased vulnerability to shocks and long term stresses. The basic determinants of under-nutrition are rooted in poverty and involve interactions between social, political, demographic, and societal conditions. (below: Conceptual framework of undernutrition; ACF (2012) “The Essential: Nutrition and Health” adapted from UNICEF 1990))



Under-nutrition has often been viewed as a problem of limited food availability and solutions for addressing under-nutrition has often focused on increasing food production. Such a perception is very simplistic and ignores a wide range of contributing factors which nutrition interventions need to address in order to achieve tangible results. Meaningful WASH & Nutrition integration requires a good understanding of complex causes and determinants of undernutrition.
Aiming for a long term, sustainable and at scale impact on under-nutrition calls for adopting a multi-sectoral approach and acting in an integrated way on all causal context-specific factors leading to under-nutrition. WASH and nutrition integration has to promote multi-level response strategies, linking curative, preventive and longer term structural actions and acting jointly on existing immediate and underlying causes of under-nutrition. In 2013, the Lancet series, has defined two types of complementary interventions to fight better against undernutrition:

a) Nutrition-sensitive interventions:
These interventions address the underlying determinants of fetal and child nutrition and development: food security, adequate care giving resources at the individual, household and community levels, access to health services and a safe and hygienic environment.

b) Nutrition-specific interventions:
These interventions address the immediate determinants of fetal and child nutrition and development: adequate food and nutrient intake, feeding, care giving and parenting practices, access to clean sanitation environment etc.

1) What characteristics WASH interventions should have to be nutrition sensitive?

2) Do you have any successful example of nutrition sensitive interventions to share with the group?

3) What methods/approaches can you use to determine WASH-related causes of undernutrition in specific contexts


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  • stesi
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Re: The conceptual framework of under-nutrition

lets start small and simple: in one of our projects in Uganda, KaramojaWelthungerhilfe constructed shelfes for dishes - to prevent that dust and soil contaminates plates,cups and cutlery (refer to attachment)...

Stephan Simon
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  • dspalthoff
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Re: The conceptual framework of under-nutrition

At UNICEF in Burkina Faso we are currently discussing potential synergies between WASH and Nutrition interventions. Conceptually, we distinguish three levels of intervention:
  1. Prevention of malnutrition (especially stunting): Community-level interventions that have a proven impact on nutrition outcomes, such as household water treatment and safe storage, hygiene promotion, elimination of open defecation, and also access to water supply (borehole drilling). These interventions would target communities in regions with high levels of chronic malnutrition.
  2. Treatment of malnutrition (underweight): Collaboration between with Health, Nutrition and WASH sectors to progressively improve WASH in Health and Nutritional Centers (access to a water source, latrines, showers, management of WASH infrastructure, hygiene promotion, water hygiene).
  3. Special interventions to support the treatment of severe underweight cases with complications: For these very vulnerable children, it was suggested to target their mothers with special hygiene promotion activities and the distribution of a WASH kit (Soap, Aquatabs), to ensure that the child can have access to clean drinking water at community level, at least for a couple of weeks.

This is all still under discussion; so any feedback on this would be appreciated.
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  • franckconcern
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Re: The conceptual framework of under-nutrition

Thanks for the opportunity to discuss this important topic.

To close the Oral faecal transmission route through soil contamination (soil - fingers - mouth/ and to avoid Environmental enteropathy), we now recommend our teams to promote the use of play mat for young children (<1000 days, )and Animals enclosure(chicken)< but none of these measures seem to work very well:
- children don't stay on the rugs,+ mothers say they can't put them on it very often as they need to take them with them for their daily work
- Chicken are left in freedom so they can find their own food in the environment.

Any other idea?

Amicalement
Franck/Concern Worldwide

Franck Flachenberg| Environmental Health Technical advisor| Concern Worldwide
13-14 Calico House Clove hitch Quay | London SW11 3TN | UK
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  • DanJones
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  • I am Advocacy Coordinator at WaterAid, particularly focusing on our 'Healthy Start' global advocacy priority to improve child health and nutrition by integrating WASH into national and international policies and practices
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Re: The conceptual framework of under-nutrition

Thanks Rebecca for a great opener, and the diagram is really useful for me.

Just a little context first on WaterAid's involvement here - our four year global advocacy priority is called 'Healthy Start' ( www.wateraid.org/healthystart ) and aims to improve child health and nutrition by integrating water, sanitation, and hygiene promotion into national and international health policies and practices. My particular focus is on the WASH and Nutrition integration, and my role is focused on advocating for this integration (so I'm not a technical expert!). Many of our Country Programmes are engaging with SUN (Scaling Up Nutrition) national platforms as a good way to build relationships outside of the 'WASH' sector and begin the dialogue about improving integration.

'Integration' is one of the hottest buzzwords around at the moment, thanks to the new Global Goals for Sustainable Development, but what do we actually mean by it? And do we all agree what it is or how to do it? I think we should all be prepared to say that we don't have all the answers on this yet, whether we are governments, international agencies or NGOs. So I'm definitely looking forward to discussing and learning, and sharpening my own thinking about what integration actually means in reality, tangibly.

For now, I was thinking of the challenges of WASH as a 'nutrition-sensitive' area/intervention. I feel that some good progress is being made both globally and nationally on 'nutrition-specific' action to end malnutrition, but that 'nutrition sensitive' is much harder to specify, quantify, measure and account for. For example, I remember visiting Tanzania a few years ago and seeing the impressive action being taken there such as food fortification (we visited a flour company fortifying their product). Fascinating stuff. And it was clear in Tanzania that the President's top level political engagement in the issue of nutrition was paying serious dividends. But flour fortification or other 'specific' interventions are much easier to tangibly invest in than the wider sensitive arena. And yet 'nutrition sensitive' is fundamental - no matter if food is fortified, if children are eating food in unhygienic, unsanitary conditions and without enough water to clean food properly, then they are bound to have infections and diarrhea that leave them without the nutrients they need.

Another challenge with 'nutrition sensitive' is how to measure government and donor investment in it. How can we ensure that so-called 'nutrition sensitive' investments are in fact 'sensitive' enough ('sensitive dominant') so that they are genuinely supporting and integrating with the fight to end malnutrition?

Looking forward to discussing!
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  • franckconcern
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Re: The conceptual framework of under-nutrition

I fully agree on the comment made about "nutrition sensitive" activities being harder to specify, quantify, measure and account for. Being in position to document changes in unhygienic, unsanitary conditions require a strong M&E system that relies not only on questionnaire but also direct observations (for ex. : % of functioning Hand washing stations - filled with water, soap available).

Sharing a set of common indicators for implementing "nutrition sensitive" interventions would be great.

Amicalement
franck

Franck Flachenberg| Environmental Health Technical advisor| Concern Worldwide
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  • RLO
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Re: The conceptual framework of under-nutrition

Thanks a lot for your postings and examples. Shows how challenging is to develop multi-sectoral approaches…

For the “BABY WASH”, what is done in the SHINE Zimbabwe project is that they set up a playpen for the children – to avoid them to run away. And probably easier to leave the chicken running freely!

In addition come to the baby WASH messages:
1. Safely dispose of all animal and human feces;
2. Wash hands with soap after fecal contact and before preparing food, eating food, or feeding children;
3. Protect children from ingesting soil and animal feces;
4. Freshly prepare children's food, or reheat to boiling prior to feeding;
5. Give children (after 6 months of exclusive breastfeeding) only drinking water that has been chlorinated.
Example from SHINE study, Zimbabwe (2014)


For the nutrition sensitive approach, in ACF we are also trying our best to monitor the results of the multi sectoral projects in place – since a couple of years we have an internal guidance on nutrition security to encourage teams to define common approach and a checklist is available to help the design of the project– see documents attached.

In addition, here is how we design characteristics of nutrition-sensitive interventions:
1) Targeting on the basis of nutritional vulnerability. For example, target groups with the highest malnutrition rates, groups that are the most vulnerable to malnutrition (children under five, pregnant women, prioritize the 1000 days window of opportunity), populations facing stress related to food security or other shocks.
2) Identifying nutrition goals to maximize opportunities. Which activities can impact on nutrition? How are the planned activities going to lead to a change in the nutritional status?) Design appropriate indicators and objectives to monitor and evaluate the impact.
3) Engaging women and including interventions to protect and promote their nutritional status, wellbeing, social status, decision making and overall empowerment as well as their ability to manage their time, resources and assets.
4) Including nutrition promotion and behavior change strategies.
5) Considering alternatives to minimize unintended negative consequences and maximize positive impact on nutrition. Right timing and duration of the intervention to influence nutritional status.

For the integration, below is an example on how ACF-IN is defining the different forms and levels of integration that WASH and Nutrition programming can achieve:




Happy to discuss further…. Thanks a lot. Rachel
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  • John Brogan
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Re: The conceptual framework of under-nutrition

Great discussion! At Terre des hommes we've integrated WASH (among other interventions like gardening) within a basic model of action to prevent acute malnutrition. This corresponds to the "strong integration" green box shared by Rachel.



Agree with Frank, it is tough to attribute ("account for") the effects of the nutrition sensitive programming to improved nutrition.
We worked on an article for Field Exchange 51, an evaluation comparing nutrition status of children under two years between sites with and without WASH intervention. Over a period of three years we saw that rate of decrease in prevalence of acute malnutrition was significantly higher in the WASH intervention site. www.ennonline.net/fex/51/healthnutwashbangladesh

Though the rates fell as we hoped, the study was an afterthought: we did not have rigorous research methods in our project design. I would be happy to hear your thoughts on
1. confirming the need for research to attribute nutrition sensitive programming (WASH) to nutrition results: should we be building this into our projects?
2. examples of how others have worked action research with nutrition sensitive programming from the project design phase --specifically for WASH.

Thanks,
John

John Brogan
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  • htuy
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Re: The conceptual framework of under-nutrition

We have created the following under-nutrition model for Guatemala:




DOWNLOAD our report "Análisis sistémico y territorial de la seguridad alimentaria y nutricional en Guatemala: consideraciones para mejorar prácticas y políticas públicas"
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Maya-Kaqchikel - Natural resource manager with more than twenty years of experience in working with government agencies, NGO, and local communities in design, execution and evaluation of complex projects linking the environment to development. Currently, I am undertaking teaching and research at IARNA/URL. In recent years, I have been actively providing technical assistance to the World Bank’s Wealth Accounting and the Valuation of Ecosystem Services (WAVES), UNEP global environmental assessment process (GEO-5 and GEO-6), and USAID´s Monitoring and Evaluation Program (MEP). Among other...
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  • franckconcern
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Re: The conceptual framework of under-nutrition

Dear all,

Concern did an extensive baseline survey for a nutrition programme in Tanzania with our partner CRED analysing various variables that might correlate with stunting. The key findings of the study are (WASH related ones are undelined): - this is an extract from a publication to come in the Journal for Tropical Paediatrics.

• Younger children 6-23months have higher odds of being stunted (risk factors) when
o living in Njombe and Iringa (compared to Mbeya)
o aged 2-3 years (compared to younger and older ones)
o male
o mother is currently pregnant (found for Njombe and Iringa only)
o maternal absence for 4-7 hours
o production of vitamin-A-rich food (where VitA rich foods were produced stunting was higher!)
o having two or more births in the last 5 years (Iringa)
o reduced frequency of buying fresh vegetables (Iringa)
o improved knowledge of hand washing practices (Iringa)

• Younger children 6-23months have lower odds of being stunted when
o Receiving deworming treatment
o from a household consuming 5 or more food groups or that has a home garden
o from households producing animal-based food (found for Njombe only)
o household is using iodised salt (found for Iringa only)

• Older children 24-59 months have higher odds of being stunted when
o mother currently breastfeeding
o maternal longer absence (4-7 hours) (Njombe)
o Urban residence (Mbeya)

• Older children 24-59 months have lower odds of being stunted when
o From households with access to improved water source or with a functioning water station
o Knowledge of hand washing practices (Iringa)
o from households consuming animal based food (Mbeya)
o Short maternal absence (1-3 hours) (Mbeya).
o Urban residence (Njombe).

Franck Flachenberg| Environmental Health Technical advisor| Concern Worldwide
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T +44 20 7801 1882 | M +44 75 12078776|franck.flachenberg@concern.net | Skype cw_franck.flachenberg|
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  • cecile
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Re: The conceptual framework of under-nutrition

Dear Frank,

A couple months ago I came across interesting IEC tools which tackled both chicken management and hygiene, developped by JICA in Egypt.I attached a couple of pictures I took at the time.I flipped through the full leaflet and the strong strong messages were 1) wash your hands 2) keep the poultry out of the house. On each page there was a drawing of a happy family (all smiling) with no chickens in the house and a sink with soap and an unhappy family with chicken wandering by the TV and people coughing and not smiling.

There is one practice that I often observe, especially when standing in line of shops and supermarkets here in Egypt, is that several people put the bank notes in their mouth in order to have free hands. This practice certainly has a significant impact on fecal contamination and maybe worms infection. Up to now I have never come across hygiene messages related to this practice in any of the hygiene awareness campains.

Kind regards,

Cécile

Cécile Laborderie
MAKATI Environnement
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