Relationship between water, sanitation, hygiene, and nutrition: what do Link NCA nutrition causal analyses say?
Jovana Dodos, Blanche Mattern, Jean Lapegue, Mathias Altmann, Myriam Ait Aissa
Defined by UNICEF as ‘the outcome of insufficient food intake and repeated infectious diseases’, undernutrition is one of the world’s most serious problems, with long-lasting harmful impacts on health and devastating consequences for social and economic development. The three main underlying causes of undernutrition, namely unsuitable or insufficient food intake, poor care practices, and infectious diseases, are directly or indirectly related to inadequate access to water, sanitation facilities, and hygiene practices (WASH). There is a growing base of evidence showing the links between poor WASH conditions, especially exposure to poor sanitation, and stunting (low height for age ratio). However, the effects of WASH interventions on wasting (low weight for height ratio) and the impact of environmental enteric dysfunction (chronic infection of small intestine caused by extended exposure to faecal pathogens) on undernutrition should be explored further. Action Against Hunger (Action Contre la Faim) promotes a participatory nutrition causal analysis, the Link NCA methodology, which is used to analyse complex, dynamic, locally specific causes of undernutrition. This article aims to assess the main findings from 12 most recent Link NCA studies, conducted from the beginning of 2014 until the end of 2016. Results show that inadequate WASH conditions are often identified as major contributors to undernutrition in the study areas. The article also provides lessons learned and a set of practical recommendations for better alignment and integration of WASH and nutrition interventions.Action Against Hunger/UNICEF/ECHO (2017) WASH’ Nutrition: A Practical Guidebook on Increasing Nutritional Impact through Integration of WASH and Nutrition Programs [online] <www.actioncontrelafaim.org/fr/content/wash-nutrition-practical-guidebook-increasing-nutritional-impact-through-integration-wash> [accessed 12 February 2017].
Action Contre la Faim (2011) Water, Sanitation and Hygiene [pdf], ACF-International Policy, Paris: ACF <www.actioncontrelafaim.org/sites/default/files/publications/fichiers/exe_bd_wash_policy_-_eng.pdf> [accessed 12 February 2017].
Action Contre la Faim (2014a) Greater Investment in Water, Sanitation and Hygiene is Key to the Fight against Under Nutrition [pdf], Paris: ACF <www.coalition-eau.org/wp-content/uploads/WASH-Advocacy-En.pdf> [accessed 6 February 2017].
Action Contre la Faim (2014b) Nutrition Security Policy [online], Paris: ACF <www.actioncontrelafaim.org/en/content/acf-international-nutrition-security-policy> [accessed 6 February 2017].
Action Contre la Faim (2014c) Factsheet: WASH in Nutrition [online], Paris: ACF <http://www.actioncontrelafaim.org/en/content/factsheet-wash-nutrition> [accessed 10 June 2017].
Action Contre la Faim (2015) Link NCA – Nutrition Causal Analysis Guidelines [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2351/catDoc26/nca_guidelines_en_web-low2.pdf> [accessed 6 June 2017].
Action Contre la Faim (2017) Link NCA – Nutrition Causal Analysis Overview [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2353/catDoc26/nca_overview_en_web-low_170601.pdf> [accessed 6 June 2017].
Action Contre la Faim/USAID/ECHO (2016) Link NCA report, Borena Zone, Ethiopia [pdf], Paris: ACF <http://linknca.org/fiche/borena_zone_oromia_region1.html> [accessed 6 June 2017].
Alderman, H.H., Elder, L.K., Goyal, A., Herforth, A.W., Hoberg, Y.T., Marini, A., Ruel-Bergeron, J., Saavedra Chanduvi, J., Shekar, M., Tiwari, S. and Zaman, H. (2013) Improving Nutrition through Multisectoral Approaches, Working Paper, Washington, DC: World Bank <http://documents.worldbank.org/curated/en/625661468329649726/Improving-nutrition-through-multisectoral-approaches> [accessed 9 December 2016].
Black, R.E., Victora, C.G., Walker, S.P., Bhutta, Z.A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., Martorell, R., Uauy, R., the Maternal and Child Nutrition Study Group (2013) ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’, Lancet 382(9890): 427–51 <http://dx.doi.org/10.1016/S0140-6736(13)60937-X>.
Blössner, M. and de Onis, M. (2005) Malnutrition: Quantifying the Health Impact at National and Local Levels [online], WHO Environmental Burden of Disease Series, No. 12, Geneva: World Health Organization <www.who.int/quantifying_ehimpacts/publications/eb12/en/> [accessed 7 June 2017].
Brown, J., Cairncross, S. and Ensink, J.H.J. (2011) ‘Water, sanitation, hygiene and enteric infections in children’, BMJ 98(8): 629–34 <http://dx.doi.org/10.1136/archdischild-2011-301528>.
Cairncross, S., Cumming, O., Jeandron, A., Rheingans, R., Ensink, J., Brown, J., Cavill, S., Baker, S., Schmidt, W.P., Amery, J., Bibby, S., Harvey, M., Howard, G., Mulligan, J., O’Connor, H., Ryan-Collins, L., Swann, P., Wijesekera, S. and Woolnough, D. (2013) Water, Sanitation and Hygiene Evidence Paper [pdf], London: UK Department for International Development <https://www.gov.uk/government/publications/water-sanitation-and-hygiene-evidence-paper> [accessed 21 December 2016].
Checkley, W., Gilman, R.H., Black, R.E., Epstein, L.D., Cabrera, L., Sterling, C.R. and Moulton, L.H. (2004) ‘Effect of water and sanitation on childhood health in a poor Peruvian periurban community’, Lancet 363(9403): 112–8 <http://dx.doi.org/10.1016/S0140-6736(03)15261-0>.
Curtis, V. and Cairncross, S. (2003) ‘Effect of washing hands with soap on diarrhoea risk in the community: a systematic review’, The Lancet Infectious Diseases 3(5): 275–81 [online] <https://www.ncbi.nlm.nih.gov/pubmed/12726975> [accessed 10 May 2017].
Dangour, A.D., Watson, L., Cumming, O., Boisson, S., Che, Y., Velleman, Y., Cavill, S., Allen, E. and Uauy, R. (2013) ‘Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutrition status of children’, The Cochrane Database of Systematic Reviews 8: CD009382 <http://dx.doi.org/10.1002/14651858.CD009382.pub2>.
Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L. and Colford Jr, J.M. (2005) ‘Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis’, The Lancet Infectious Diseases 5(1): 42–52 <http://dx.doi.org/10.1016/S1473-3099(04)01253-8>.
Humphrey, J.H. (2009) ‘Child undernutrition, tropical enteropathy, toilets, and handwashing’, The Lancet 374(9694): 1032–5 <http://dx.doi.org/10.1016/S0140-6736(09)60950-8>.
International Food Policy Research Institute (2016) Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030 [pdf], Washington, DC: IFPRI <http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/filename/130565.pdf> [accessed 12 May 2017].
Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet 366(9481): 225–33 <https://doi.org/10.1016/S0140-6736(05)66912-7>.
Mwase, I., Mutoro, A., Owino, V., Garcia, A.L. and Wright, C.M. (2016) ‘Poor infant feeding practices and high prevalence of malnutrition in urban slum child care centres in Nairobi: a pilot study’, Journal of Tropical Pediatrics 62(1): 46–54 <http://dx.doi.org/10.1093/tropej/fmv071>.
Prüss-Ustun, A., Bonjour, S. and Corvalan, C. (2008) ‘The impact of the environment on health by country: a meta-synthesis’, Environmental Health 7 <http://dx.doi.org/10.1186/1476-069X-7-7>.
Rodríguez, L., Cervantes, E. and Ortiz, R. (2011) ‘Malnutrition and gastrointestinal and respiratory infections in children: a public health problem’, International Journal of Environmental Research and Public Health 8(4): 1174–1205 <https://dx.doi.org/10.3390%2Fijerph8041174>.
Spears, D. (2013) How Much International Variation in Child Height Can Sanitation Explain? [online], Policy Research Working Paper, Washington, DC: World Bank <http://elibrary.worldbank.org/doi/abs/10.1596/1813-9450-6351> [accessed 9 December 2016].
Strunz, E.C., Addiss, D.G., Stocks, M.E., Ogden, S. Utzinger, J. and Freeman, M.C. (2014) ‘Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis’, PLOS Medicine 11(3): e1001620 <https://doi.org/10.1371/journal.pmed.1001620>.
UNICEF (1990) Strategy for Improved Nutrition of Children and Women in Developing Countries [pdf], New York: UNICEF <www.ceecis.org/iodine/01_global/01_pl/01_01_other_1992_unicef.pdf> [accessed 7 June 2017].
UNICEF/WHO/World Bank Group (2015) Levels and Trends in Child Malnutrition [pdf], New York: UNICEF; Geneva: WHO; Washington, DC: World Bank <https://www.unicef.org/media/files/JME_2015_edition_Sept_2015.pdf> [accessed 13 January 2017].
Victora, C.G., de Onis, M., Hallal, P.C., Blössner, M. and Shrimpton, R. (2010) ‘Worldwide timing of growth faltering: revisiting implications for interventions’, Pediatrics 125(3): e473–80 <http://dx.doi.org/10.1542/peds.2009-1519>.
WHO (2014a) Preventing Diarrhoea through Better Water, Sanitation and Hygiene: Exposures and Impacts in Low- and Middle-Income Countries [pdf], Geneva: WHO <www.who.int/water_sanitation_health/publications/preventing-diarrhoea/en/> [accessed 13 January 2017].
WHO (2014b) WHA Global Nutrition Targets 2025: Wasting Policy Brief [pdf], Geneva: WHO <www.who.int/nutrition/topics/globaltargets_wasting_policybrief.pdf> [assessed 10 May 2017].
WHO (2016) Preventing Disease through Healthy Environments: A Global Assessment of the Burden of Disease from Environmental Risks [pdf] Geneva: WHO <www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/> [accessed 9 December 2016].
Wolf, J., Prüss-Ustün, A., Cumming, O., Bartram, J., Bonjour, S., Cairncross, S., Clasen, T., Colford, J.M. Jr, Curtis, V., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Jeandron, A., Johnston, R.B., Mäusezahl, D., Mathers, C., Neira, M. and Higgins, J.P. (2014) ‘Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression’, Tropical Medicine and International Health 19: 928–42 <http://dx.doi.org/10.1111/tmi.12331>.
Action Against Hunger/UNICEF/ECHO (2017) WASH’ Nutrition: A Practical Guidebook on Increasing Nutritional Impact through Integration of WASH and Nutrition Programs [online] <www.actioncontrelafaim.org/fr/content/wash-nutrition-practical-guidebook-increasing-nutritional-impact-through-integration-wash> [accessed 12 February 2017].
Action Contre la Faim (2011) Water, Sanitation and Hygiene [pdf], ACF-International Policy, Paris: ACF <www.actioncontrelafaim.org/sites/default/files/publications/fichiers/exe_bd_wash_policy_-_eng.pdf> [accessed 12 February 2017].
Action Contre la Faim (2014a) Greater Investment in Water, Sanitation and Hygiene is Key to the Fight against Under Nutrition [pdf], Paris: ACF <www.coalition-eau.org/wp-content/uploads/WASH-Advocacy-En.pdf> [accessed 6 February 2017].
Action Contre la Faim (2014b) Nutrition Security Policy [online], Paris: ACF <www.actioncontrelafaim.org/en/content/acf-international-nutrition-security-policy> [accessed 6 February 2017].
Action Contre la Faim (2014c) Factsheet: WASH in Nutrition [online], Paris: ACF <http://www.actioncontrelafaim.org/en/content/factsheet-wash-nutrition> [accessed 10 June 2017].
Action Contre la Faim (2015) Link NCA – Nutrition Causal Analysis Guidelines [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2351/catDoc26/nca_guidelines_en_web-low2.pdf> [accessed 6 June 2017].
Action Contre la Faim (2017) Link NCA – Nutrition Causal Analysis Overview [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2353/catDoc26/nca_overview_en_web-low_170601.pdf> [accessed 6 June 2017].
Action Contre la Faim/USAID/ECHO (2016) Link NCA report, Borena Zone, Ethiopia [pdf], Paris: ACF <http://linknca.org/fiche/borena_zone_oromia_region1.html> [accessed 6 June 2017].
Alderman, H.H., Elder, L.K., Goyal, A., Herforth, A.W., Hoberg, Y.T., Marini, A., Ruel-Bergeron, J., Saavedra Chanduvi, J., Shekar, M., Tiwari, S. and Zaman, H. (2013) Improving Nutrition through Multisectoral Approaches, Working Paper, Washington, DC: World Bank <http://documents.worldbank.org/curated/en/625661468329649726/Improving-nutrition-through-multisectoral-approaches> [accessed 9 December 2016].
Black, R.E., Victora, C.G., Walker, S.P., Bhutta, Z.A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., Martorell, R., Uauy, R., the Maternal and Child Nutrition Study Group (2013) ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’, Lancet 382(9890): 427–51 <http://dx.doi.org/10.1016/S0140-6736(13)60937-X>.
Blössner, M. and de Onis, M. (2005) Malnutrition: Quantifying the Health Impact at National and Local Levels [online], WHO Environmental Burden of Disease Series, No. 12, Geneva: World Health Organization <www.who.int/quantifying_ehimpacts/publications/eb12/en/> [accessed 7 June 2017].
Brown, J., Cairncross, S. and Ensink, J.H.J. (2011) ‘Water, sanitation, hygiene and enteric infections in children’, BMJ 98(8): 629–34 <http://dx.doi.org/10.1136/archdischild-2011-301528>.
Cairncross, S., Cumming, O., Jeandron, A., Rheingans, R., Ensink, J., Brown, J., Cavill, S., Baker, S., Schmidt, W.P., Amery, J., Bibby, S., Harvey, M., Howard, G., Mulligan, J., O’Connor, H., Ryan-Collins, L., Swann, P., Wijesekera, S. and Woolnough, D. (2013) Water, Sanitation and Hygiene Evidence Paper [pdf], London: UK Department for International Development <https://www.gov.uk/government/publications/water-sanitation-and-hygiene-evidence-paper> [accessed 21 December 2016].
Checkley, W., Gilman, R.H., Black, R.E., Epstein, L.D., Cabrera, L., Sterling, C.R. and Moulton, L.H. (2004) ‘Effect of water and sanitation on childhood health in a poor Peruvian periurban community’, Lancet 363(9403): 112–8 <http://dx.doi.org/10.1016/S0140-6736(03)15261-0>.
Curtis, V. and Cairncross, S. (2003) ‘Effect of washing hands with soap on diarrhoea risk in the community: a systematic review’, The Lancet Infectious Diseases 3(5): 275–81 [online] <https://www.ncbi.nlm.nih.gov/pubmed/12726975> [accessed 10 May 2017].
Dangour, A.D., Watson, L., Cumming, O., Boisson, S., Che, Y., Velleman, Y., Cavill, S., Allen, E. and Uauy, R. (2013) ‘Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutrition status of children’, The Cochrane Database of Systematic Reviews 8: CD009382 <http://dx.doi.org/10.1002/14651858.CD009382.pub2>.
Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L. and Colford Jr, J.M. (2005) ‘Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis’, The Lancet Infectious Diseases 5(1): 42–52 <http://dx.doi.org/10.1016/S1473-3099(04)01253-8>.
Humphrey, J.H. (2009) ‘Child undernutrition, tropical enteropathy, toilets, and handwashing’, The Lancet 374(9694): 1032–5 <http://dx.doi.org/10.1016/S0140-6736(09)60950-8>.
International Food Policy Research Institute (2016) Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030 [pdf], Washington, DC: IFPRI <http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/filename/130565.pdf> [accessed 12 May 2017].
Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet 366(9481): 225–33 <https://doi.org/10.1016/S0140-6736(05)66912-7>.
Mwase, I., Mutoro, A., Owino, V., Garcia, A.L. and Wright, C.M. (2016) ‘Poor infant feeding practices and high prevalence of malnutrition in urban slum child care centres in Nairobi: a pilot study’, Journal of Tropical Pediatrics 62(1): 46–54 <http://dx.doi.org/10.1093/tropej/fmv071>.
Prüss-Ustun, A., Bonjour, S. and Corvalan, C. (2008) ‘The impact of the environment on health by country: a meta-synthesis’, Environmental Health 7 <http://dx.doi.org/10.1186/1476-069X-7-7>.
Rodríguez, L., Cervantes, E. and Ortiz, R. (2011) ‘Malnutrition and gastrointestinal and respiratory infections in children: a public health problem’, International Journal of Environmental Research and Public Health 8(4): 1174–1205 <https://dx.doi.org/10.3390%2Fijerph8041174>.
Spears, D. (2013) How Much International Variation in Child Height Can Sanitation Explain? [online], Policy Research Working Paper, Washington, DC: World Bank <http://elibrary.worldbank.org/doi/abs/10.1596/1813-9450-6351> [accessed 9 December 2016].
Strunz, E.C., Addiss, D.G., Stocks, M.E., Ogden, S. Utzinger, J. and Freeman, M.C. (2014) ‘Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis’, PLOS Medicine 11(3): e1001620 <https://doi.org/10.1371/journal.pmed.1001620>.
UNICEF (1990) Strategy for Improved Nutrition of Children and Women in Developing Countries [pdf], New York: UNICEF <www.ceecis.org/iodine/01_global/01_pl/01_01_other_1992_unicef.pdf> [accessed 7 June 2017].
UNICEF/WHO/World Bank Group (2015) Levels and Trends in Child Malnutrition [pdf], New York: UNICEF; Geneva: WHO; Washington, DC: World Bank <https://www.unicef.org/media/files/JME_2015_edition_Sept_2015.pdf> [accessed 13 January 2017].
Victora, C.G., de Onis, M., Hallal, P.C., Blössner, M. and Shrimpton, R. (2010) ‘Worldwide timing of growth faltering: revisiting implications for interventions’, Pediatrics 125(3): e473–80 <http://dx.doi.org/10.1542/peds.2009-1519>.
WHO (2014a) Preventing Diarrhoea through Better Water, Sanitation and Hygiene: Exposures and Impacts in Low- and Middle-Income Countries [pdf], Geneva: WHO <www.who.int/water_sanitation_health/publications/preventing-diarrhoea/en/> [accessed 13 January 2017].
WHO (2014b) WHA Global Nutrition Targets 2025: Wasting Policy Brief [pdf], Geneva: WHO <www.who.int/nutrition/topics/globaltargets_wasting_policybrief.pdf> [assessed 10 May 2017].
WHO (2016) Preventing Disease through Healthy Environments: A Global Assessment of the Burden of Disease from Environmental Risks [pdf] Geneva: WHO <www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/> [accessed 9 December 2016].
Wolf, J., Prüss-Ustün, A., Cumming, O., Bartram, J., Bonjour, S., Cairncross, S., Clasen, T., Colford, J.M. Jr, Curtis, V., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Jeandron, A., Johnston, R.B., Mäusezahl, D., Mathers, C., Neira, M. and Higgins, J.P. (2014) ‘Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression’, Tropical Medicine and International Health 19: 928–42 <http://dx.doi.org/10.1111/tmi.12331>.
Action Against Hunger/UNICEF/ECHO (2017) WASH’ Nutrition: A Practical Guidebook on Increasing Nutritional Impact through Integration of WASH and Nutrition Programs [online] <www.actioncontrelafaim.org/fr/content/wash-nutrition-practical-guidebook-increasing-nutritional-impact-through-integration-wash> [accessed 12 February 2017].
Action Contre la Faim (2011) Water, Sanitation and Hygiene [pdf], ACF-International Policy, Paris: ACF <www.actioncontrelafaim.org/sites/default/files/publications/fichiers/exe_bd_wash_policy_-_eng.pdf> [accessed 12 February 2017].
Action Contre la Faim (2014a) Greater Investment in Water, Sanitation and Hygiene is Key to the Fight against Under Nutrition [pdf], Paris: ACF <www.coalition-eau.org/wp-content/uploads/WASH-Advocacy-En.pdf> [accessed 6 February 2017].
Action Contre la Faim (2014b) Nutrition Security Policy [online], Paris: ACF <www.actioncontrelafaim.org/en/content/acf-international-nutrition-security-policy> [accessed 6 February 2017].
Action Contre la Faim (2014c) Factsheet: WASH in Nutrition [online], Paris: ACF <http://www.actioncontrelafaim.org/en/content/factsheet-wash-nutrition> [accessed 10 June 2017].
Action Contre la Faim (2015) Link NCA – Nutrition Causal Analysis Guidelines [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2351/catDoc26/nca_guidelines_en_web-low2.pdf> [accessed 6 June 2017].
Action Contre la Faim (2017) Link NCA – Nutrition Causal Analysis Overview [pdf], Paris: ACF <http://document.linknca.com//30/30/supports/2353/catDoc26/nca_overview_en_web-low_170601.pdf> [accessed 6 June 2017].
Action Contre la Faim/USAID/ECHO (2016) Link NCA report, Borena Zone, Ethiopia [pdf], Paris: ACF <http://linknca.org/fiche/borena_zone_oromia_region1.html> [accessed 6 June 2017].
Alderman, H.H., Elder, L.K., Goyal, A., Herforth, A.W., Hoberg, Y.T., Marini, A., Ruel-Bergeron, J., Saavedra Chanduvi, J., Shekar, M., Tiwari, S. and Zaman, H. (2013) Improving Nutrition through Multisectoral Approaches, Working Paper, Washington, DC: World Bank <http://documents.worldbank.org/curated/en/625661468329649726/Improving-nutrition-through-multisectoral-approaches> [accessed 9 December 2016].
Black, R.E., Victora, C.G., Walker, S.P., Bhutta, Z.A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., Martorell, R., Uauy, R., the Maternal and Child Nutrition Study Group (2013) ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’, Lancet 382(9890): 427–51 <http://dx.doi.org/10.1016/S0140-6736(13)60937-X>.
Blössner, M. and de Onis, M. (2005) Malnutrition: Quantifying the Health Impact at National and Local Levels [online], WHO Environmental Burden of Disease Series, No. 12, Geneva: World Health Organization <www.who.int/quantifying_ehimpacts/publications/eb12/en/> [accessed 7 June 2017].
Brown, J., Cairncross, S. and Ensink, J.H.J. (2011) ‘Water, sanitation, hygiene and enteric infections in children’, BMJ 98(8): 629–34 <http://dx.doi.org/10.1136/archdischild-2011-301528>.
Cairncross, S., Cumming, O., Jeandron, A., Rheingans, R., Ensink, J., Brown, J., Cavill, S., Baker, S., Schmidt, W.P., Amery, J., Bibby, S., Harvey, M., Howard, G., Mulligan, J., O’Connor, H., Ryan-Collins, L., Swann, P., Wijesekera, S. and Woolnough, D. (2013) Water, Sanitation and Hygiene Evidence Paper [pdf], London: UK Department for International Development <https://www.gov.uk/government/publications/water-sanitation-and-hygiene-evidence-paper> [accessed 21 December 2016].
Checkley, W., Gilman, R.H., Black, R.E., Epstein, L.D., Cabrera, L., Sterling, C.R. and Moulton, L.H. (2004) ‘Effect of water and sanitation on childhood health in a poor Peruvian periurban community’, Lancet 363(9403): 112–8 <http://dx.doi.org/10.1016/S0140-6736(03)15261-0>.
Curtis, V. and Cairncross, S. (2003) ‘Effect of washing hands with soap on diarrhoea risk in the community: a systematic review’, The Lancet Infectious Diseases 3(5): 275–81 [online] <https://www.ncbi.nlm.nih.gov/pubmed/12726975> [accessed 10 May 2017].
Dangour, A.D., Watson, L., Cumming, O., Boisson, S., Che, Y., Velleman, Y., Cavill, S., Allen, E. and Uauy, R. (2013) ‘Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutrition status of children’, The Cochrane Database of Systematic Reviews 8: CD009382 <http://dx.doi.org/10.1002/14651858.CD009382.pub2>.
Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L. and Colford Jr, J.M. (2005) ‘Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis’, The Lancet Infectious Diseases 5(1): 42–52 <http://dx.doi.org/10.1016/S1473-3099(04)01253-8>.
Humphrey, J.H. (2009) ‘Child undernutrition, tropical enteropathy, toilets, and handwashing’, The Lancet 374(9694): 1032–5 <http://dx.doi.org/10.1016/S0140-6736(09)60950-8>.
International Food Policy Research Institute (2016) Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030 [pdf], Washington, DC: IFPRI <http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/filename/130565.pdf> [accessed 12 May 2017].
Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet 366(9481): 225–33 <https://doi.org/10.1016/S0140-6736(05)66912-7>.
Mwase, I., Mutoro, A., Owino, V., Garcia, A.L. and Wright, C.M. (2016) ‘Poor infant feeding practices and high prevalence of malnutrition in urban slum child care centres in Nairobi: a pilot study’, Journal of Tropical Pediatrics 62(1): 46–54 <http://dx.doi.org/10.1093/tropej/fmv071>.
Prüss-Ustun, A., Bonjour, S. and Corvalan, C. (2008) ‘The impact of the environment on health by country: a meta-synthesis’, Environmental Health 7 <http://dx.doi.org/10.1186/1476-069X-7-7>.
Rodríguez, L., Cervantes, E. and Ortiz, R. (2011) ‘Malnutrition and gastrointestinal and respiratory infections in children: a public health problem’, International Journal of Environmental Research and Public Health 8(4): 1174–1205 <https://dx.doi.org/10.3390%2Fijerph8041174>.
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