1. Office of Global Health and HIV (OGHH) Office of Overseas Programming & Training Support (OPATS) Integrating WASH and Nutrition Water, Sanitation, and Hygiene Training Package

2. WASH UNICEF Framework for Child Malnutrition

3. Key Nutrition Terminology  Matching Quiz – Working with a partner, match the nutrition term to its definition. – You have three minutes to complete the activity. – Stand up when you are finished.

4. Biological Linkages Between WASH and Nutrition Overview of Topics: 1.Diarrheal Disease 2.Environmental Enteric Dysfunction (also known as Environmental Enteropathy)

5. 1. The Role of Diarrheal Disease  After exclusive breastfeeding in the early months of life, children 6–17 months of age show an increase in the incidence of diarrhea that correlates with the introduction of complementary feeding. 1  In developing countries, children under age 2 experience an average of three episodes of diarrhea, most between 6–11 months of age. 2  Unsafe water was considered the primary cause of diarrhea in children transitioning from an exclusive breastfeeding diet, but recent evidence also points to unsafe food. 3

6. Vicious Cycle between Diarrhea and Undernutrition DiarrheaUndernutrition Children with diarrhea eat less and absorb fewer nutrients from their food Undernourished children are more susceptible to diarrhea when exposed to fecal material from their environment

7. More than Just Diarrhea: Environmental Enteric Dysfunction (EED)  Inflammation of the gut, caused by chronic childhood exposure to fecal microbes and poor sanitation that results in nutrients being diverted from growth and toward immune stimulation. 1  Not symptomatic, but appears to be associated with stunting. Healthy lining of the gut Inflamed lining of the gut

8. Environmental Enteric Dysfunction (EED)  Evidence suggests an effect of WASH interventions on linear growth (stunting) that is independent of its effect on diarrhea.  Also called Environmental Enteropathy or Tropical Enteropathy Poor Sanitation and Hygiene Child Undernutrition Diarrhea Environmental Enteric Dysfunction

9. SHINE Study in Zimbabwe  Observed babies to measure what they put in their mouths, then conducted microbiological analysis of samples

10. The Fecal-Oral Transmission Cycle for Babies Feces Fields/ Floors Fluids Fingers Flies Food Diaper/ Laundry Water Animal Feces Dirty Hands

11. The Fecal-Oral Transmission Cycle and Protective Barriers for Babies Feces Fields/ Floors Fluids Fingers Flies Food Diaper/ Laundry Water Animal Feces Dirty Hands Sanitation Safe Water Hygiene Protective Play Space

12. Breaking the Cycle  What are some WASH actions that could break the fecal/oral contamination cycle for nutrition? – Feces management – Water treatment and storage – Handwashing with soap – Food hygiene – Animal management/Protective play space

13. Barriers to Change in our Country  What are possible barriers to behavior change around WASH related to nutrition outcomes? – Availability of water, soap, basins for washing food, dish drying racks – Water treatment options and safe storage and handling of water and water serving implements. – Food hygiene – Cultural norms around child rearing, food preparation and eating practices, complementary feeding practices, and defecation – Livestock management practices, availability of space or resources to separate livestock

14. Small Group Task As a group, prepare a response to each of the following questions and nominate a group member to report out: 1. Does this activity already have elements of WASH/nutrition integration? If so, please identify them. 2.Do you think this activity could incorporate additional WASH/nutrition considerations? 3.What are the barriers or challenges for the community to address WASH/nutrition in the context of this activity? 4.What are the challenges for the service provider (health worker, Volunteer, etc.) in integrating WASH/nutrition for this activity? 5.How would you incorporate WASH/nutrition into this activity?