What does evidence on nutrition and water, sanitation and hygiene mean for programming and policy?

This blog was written by Megan Wilson-Jones and Kyla Smith. Megan Wilson-Jones is Senior Policy Analyst for Health and Hygiene at WaterAid UK. Kyla Smith is Research Manager at WaterAid UK. This blog was written in collaboration with the UNC session organisers Action Against Hunger, the World Bank and the SHARE Consortium.

2019 has seen much debate around the results of major studies into the impact of water, sanitation and hygiene (WASH) interventions on childhood stunting. What implications does the evidence have for WASH for nutrition programming and policy? Megan Wilson-Jones and Kyla Smith, with Action Against Hunger, the World Bank and the SHARE Consortium, take a view from a collaboration and partnership session at the University of North Carolina WASH and Health conference.

Closing the gap: translating research into practice

The latest evidence linking WASH interventions with childhood stunting – particularly from the WASH Benefits Bangladesh and Kenya, and SHINE trials – has important implications for future programming, policy and research in WASH and nutrition, as outlined in the Consensus Statement published in BMC Medicine.

At October’s WASH and health: where science meets policy conference at the University of North Carolina in the USA, participants from academia, donors, governments and NGOs came together in a session to chart a path towards improved multi-stakeholder collaboration and partnerships. They aimed to better understand recent research findings, improve study design and prioritisation, and provide practical ideas for uptake and translation of research findings into policy and practice.

Although this was only an initial discussion on the topic, common themes and recommendations emerged.

1. We need to start joint planning early and at the beginning

Early joint planning of programmes across diverse stakeholders and sectors, including academics, funders and implementers, is critical to ensuring research priorities are contextually appropriate and replicable in real-world settings. Defined entry points, agreed by all stakeholders, are important to help collaboration.

Recommendations:

• Funders and donors: Encourage WASH and nutrition implementing agencies and researchers to collaborate, and provide the space and funds to do so.
• Researchers: Involve cross-sector front-line participants and implementers from the beginning in a meaningful way.
• Implementers: Engage with research institutions and seek out new partnerships and perspectives – this requires time, effort and persistence.
• All: Engage in research prioritisation platforms with cross-sectoral, cross-disciplinary engagement.

2. We may not all see eye-to-eye, but different sectors and actors must come together instead of deepening silos

Research design should be responsive and include partnering with government, implementers, citizens and others who will use the findings. Research should be designed to ask ‘how’ and ‘why’ questions to identify WASH interventions that can bring sustained and inclusive WASH access, and we must consider the implications of the types of question posed, especially their value and risks in a real-world context.

Researchers should strive to understand both the economic and social contexts within local communities before designing WASH interventions. Necessary transformational approaches cannot always be carried out by one sector alone. Throughout a child’s life, and at each developmental stage, safe WASH needs and requirements are likely to change. By better integrating WASH with health and nutrition along the continuum of healthcare, we can deliver the appropriate interventions at the appropriate time.

Recommendations:

• Researchers: Consider the replicability of research-related interventions into programmes and projects in the field. Interventions should meet basic quality and internationally recognised standards, without becoming too complex or too costly.
• Donors: Fund multi-stakeholder research consortia to answer key research gaps – specifically the ‘how’ questions – and support longer funding cycles and innovative research approaches.
• Implementers: Seek out partnerships with researchers to feed into research, and consider how to work with academics to better capture evidence and lessons from ongoing programming.

3. Share results appropriately for each target audience

Donors, implementers and policy makers are not always able to digest the nuances, mixed findings and complexities of WASH and nutrition research results. Studies like the Zimbabwe SHINE trial have caused some donors to dismiss the relevance of WASH and nutrition interventions altogether.

We must summarise the evidence and present it in easily understandable formats to help advocate context-relevant WASH and nutrition interventions. Equally importantly, implementing organisations must work closely with researchers to understand the implications that new study results and broader evidence have on ongoing and future interventions.1

Recommendation:

• WASH researchers and implementers: Help non-technical audiences, especially donors, to better understand the different components of WASH through simpler communication, helping to make clear which interventions and actions have what effect, and on which outcomes.

4. What should we be doing more of? What should we stop doing?

Right now, we have a window of opportunity to establish more multisectoral and integrated interventions, because of increasing global recognition of the importance of WASH in health, nutrition and agriculture. This broadens the scope from designing narrow WASH interventions to wider approaches, such as preventing healthcare-acquired infections, increasing food production and building resilience to climate change.

From a practitioner’s point of view, it appears to be easier for the WASH sector to integrate into the nutrition sector than vice versa. WASH practitioners should consider maximising the impact of WASH interventions by better targeting programmes on the basis of nutrition-vulnerability or need, targeting to groups such as pregnant women and children under two years old.

Recommendations:

• Coordination and collaboration: All stakeholders should take responsibility for reaching out to other sectors and establishing platforms for regular engagement and collaboration.

> Watch our short film, created with Action Against Hunger, summarising recommendations from our research Practical pathways to integrate nutrition and WASH.

Where do we go from here?

We are at risk of paralysing ourselves with research or lack thereof – and are tying ourselves [as the WASH sector] in knots.

– UNC session participant.

Discussions between WASH researchers, donors and practitioners have certainly highlighted the complexity of WASH for nutrition research design. Throughout the UNC conference several statements were made encouraging that we consider studies in the context of the broader body of evidence and stop doing simple, standalone interventions.

There was a renewed call that reinforced the need to do better – for us all to be better at collaboration, considering the approach and end goal of the research we design, and clearly communicating findings and implications for all stakeholders.

Based on the discussions in this session, and complemented by analysis from the Consensus Statement, and a new response from WHO and UNICEF, it is clear that overall these studies highlight the need “to be doing more WASH for nutrition work, not less.”

1 This may not apply for acute malnutrition in emergency settings, where relatively simple, low-cost interventions have been shown to be effective (e.g. TISA trial in Senegal with ACF and LSHTM).