Dear all,

my name is Mathias Altmann and I'm operational research advisor at ACF.
We are currently conducting an operational research named: “Benefits of a household WASH package to Community Management of Acute Malnutrition (CMAM) program” – The OUADINUT study - Chad:

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, decrease length of stay, and relapses after successful discharge.
In order to test these hypotheses, Action Contre la Faim is currently implementing a matched-cluster randomized controlled trial in Mao and Mondo health districts, Kanem region in Chad, comparing two groups: nutritional rehabilitation standard protocol vs. nutritional rehabilitation + “household WASH package”.
The “household WASH package” includes: i/ Household water treatment and hygiene kit (water container, water disinfection consumables, soap, cup, hygiene promotion leaflet) provided at beginning of SAM treatment; ii/ sessions of Hygiene promotion provided weekly at health center level iii/ Household visits and hygiene sessions made during the treatment; // group discussion on hygiene and care practices made with mother at community level after successful discharge
2000 children, aged between 6 and 59 months, admitted to 20 OTP centers for SAM (outpatient treatment program for severe acute malnutrition) will be included into the study during 8 months (2 months treatment, and 6 months after successful discharge). Primary evaluation outcomes are length of stay and relapse rate, while secondary outcomes include anthropometric status (Weight for Height Z-score, Height for Age Z-score, MUAC), number of diarrhea episodes, home water quality and hygiene practices.
Recruitment of the participants is in progress and the first results of the study are expected in December 2016.
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).

In order to explain the different concepts around evidence-based, I wanted to highlight the 2 types of information we usually test in operational research:
- information on risk factors: for exemple, diarrhea is associated with wasting
- information on impact: exemple: the Ouadinut study: do WASH interventions reduce/prevent wasting ?

While the first type of study is easier to conduct and clearly demonstrate associations between WASH-related factors and under-nutrition, the second type of study is much more complicated to conduct and no clear evidence do exist that WASH prevent under-nutrition. The Shine, the WASH-Benefit and the Ouadinut studies will hopefully achieve to fill this gap.

Best,
Mathias

Which level of integration is needed?

I would like to complement my first post. The intention of the post was to first look at WASH, at Nutrition and their relation. Perhaps discussion becomes more tangible, if we extend the discussion also to the question, which level of integration is needed.

Public health officials continue to call for breaking up the sector silos and moving away from vertical approaches of programming towards horizontal approaches. Bery et al. (2015 - Horizontal challenges: WASH and Nutrition integration ) argues that vertical programming obviously is not delivering the results that countries need to develop and thrive.

Both WASH and Nutrition have public health improvements as their overarching aim, but opinions differ when it comes to the question, whether a coexistence or an overlap of WASH and Nutrition activities (convergence) are sufficient or whether strong integration is required to realise better outcomes. Convergence of programmes means acting simultaneously in a common interest, with an overlapping delivery of interventions in the geographical area and little coordination. Integrated programmes jointly deliver coordinated WASH and Nutrition interventions with the same geographical focus and target groups.

Nonetheless, future efforts for linking WASH and Nutrition will have to take into account the analysis of costs (e.g. time spent in coordination) and benefits (e.g. health gains) as well as a better understanding on incentives of linking these two thematic areas. Integrated programming can happen at many levels and may take different forms. WHO et al. 2015 ( Improving nutrition outcomes with better water, sanitation and hygiene ) recommends to build on what exits, to increase integration only when worthwhile, document and reflect on lessons learnt and further refine and improve joint efforts.

Do you think that a) improving the convergence of WASH and Nutrition or b) a strong integration is required to achieve better health and nutrition outcomes? Please share your experiences from practice. How does best-practice look in reality?

The need for integration now (?) by Johannes Rück (GTO / German WASH Network)

Some people talk about linking WASH and Nutrition, others about WASH in Nutrition.

WASH actors generally view themselves as a part of the “WASH sector”. From their perspective, they are quick to label other developmental topics also as “sectors”. In the preparation of Bonn WASH Nutrition Forum 2015 , we (secretariat of the German WASH Network) also spoke of “breaking down sector silos or thinking”. We wanted to foster “sector collaboration” and created the logo below. Obviously we were in the “WASH and Nutrition” frame of mind.


At the Bonn WASH and Nutrition Forum 2015, we learned from nutrition experts that they do not describe themselves as a “sector”, but as an “outcome” of multi-sector efforts, including WASH. This puts “WASH in Nutrition” and the picture would therefore look as follows:



This picture implies a on-way integration of WASH into Nutrition. While many Nutrition strategies or country plans already include WASH interventions as a vital contribution to achieve nutrition outcomes, only a few WASH programmes include Nutrition components and massages. Nevertheless, there is an ongoing discussion about a two-way integration and the integration of Nutrition in WASH.

Following the approach of the Bonn WASH Nutrition Forum 2015, WASH and Nutrition actors must – in a first step – get to know and understand each other.

I would first like to discuss first whether we have a unified picture of WASH, of Nutrition and of their relation.

What are their differences and what are their commonalities?

Which picture do you think is more appropriate and why?

What does this mean in terms of integration or collaboration?

Please give practical examples.