Environmental Enteropathy and Baby Wash

Testing community interventions to reduce infant fecal exposure in rural Zambia:

Dadirai Fundira – Cornell UniversityKelly Alexander – CARE USA

Background: The Problem

Stunting

Short stature for age

Affects a quarter of children in developing countries

Develops between conception and the first 2 years of life

LAZ Z score -2

Background: Why we care

165 millionConsequences: Poor cognitive development Poor educational outcomes Lower adult wages Nutrition-related chronic diseases

What is causing all of this stunting?

Cause 1: poor dietThe best studies caused a 0.7 Z score

improvement. BUT:the average growth deficit of African and Asian

children is -2.0 ZAt best, diet solved 33% of the problem.Cause 2: Diarrhea

The Lancet Nutrition Series (2008) concluded that by implementing sanitation and hygiene

interventions with 99% coverage, child malnutrition would be reduced by only 2.4%

Cause 3: Environmental Enteropathy In 2009 Jean Humphrey put forward the

hypothesis that EE primary causal pathway from poor sanitation and hygiene to stunting

Source: World Bank, accessed 6.23.11http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTWAT/EXTTOPSANHYG/

6

Babies are fed on *Ground in the yard (60-80% E coli+) or *Kitchen floor

(81% E coli+)

% HH with E coli + sample

E coil/Per gram

Average E ColiPer Day

Infant Food 0% 0 0

Drinking Water 54% 2 800

Soil in laundry area

60-80% 70 1,400

Chicken feces 100% 10,000,000 10,000,000

Ngure et al,2013

% HH with E coli + sample

E coil/Per gram

Average E ColiPer Day

Infant Food 0% 0 0

Drinking Water 54% 2 800

Soil in laundry area

60-80% 70 1,400

Chicken feces 100% 10,000,000 10,000,000

Clearly, kids must stop eating dirt and chicken poop!

Ngure et al,2013

Geophagia, dirty hands

LaundryWater

Nappy Handling

Protective Play Space

for babies!

Baby WASH: a new paradigm

Ngure et al,2013

Methods: The Baby WASH interventions

Commercial Community-built

Methods: Context

Zambia Lundazi district

(Eastern province) 6 intervention villages

30 households Nutrition at the Center

Integrated project of CARE Zambia (WASH, nutrition, food security and gender)

One Health Study Nested within Nutrition

at the Center intervention areas

One Health Phases

Participatory workshops to

build, prepare, and explore solutions to

babies eating feces

Select & sensitize 6 villages

Recruit Mothers &

Babies (30 HH)

Conduct Baseline Survey &

Observation (30 HH)

Introduce Baby WASH

Module6

villages

3 VillagesCommercial

Play Yard

3 Villages Community

Design

Data Analysi

s

Consent &

interview family;

introduce communi

ty solution

Interview mother, 24 hour recall,

counseling

Interview, 24 hour recall,

counseling, Baby &

HH observati

on

Interview, 24 hour recall,

counseling

Interview, 24 hour recall,

counseling, Baby &

HH observati

on

Consent & interview family

re: reactions to EE module, Introduce commercial play

yard

Trials of Improved Practices (TIPs)

Trials of Improved Practices (TIPs)

Visit 1, +0wk

Visit 2, +2wk

Visit 3, +4wk

Visit 1, +0wk

Visit 2, +2wk

Visit 3, +4wk

PLANNING & PROTOCOL

PHASE 1 2 PHASE 3 4

Results: study participants

6 villages, 30 HH - Baseline Participants

24 HH

Recruited for TIPs

21 HH Participated

11 HH receive commercial play yard (3 villages)

10 HH receive community built play yard (3 villages)

3 HH lost to follow-up

30 HH baseline observation

Received Intervention and not lost to follow-up• 11 HH commercial playard• 10 HH community-built playard

Results: Baseline n=30

Water sources 47% unprotected

Latrine ownership 37% own latrine

Handwashing 231HW events/455

opportunities (50%) 6% HWWS

Median 1 HW event for babies

Geophagy 98% caregiver reported 100% observed

Feces in the household yard

Feces in the household yard

Even households with latrines had observable human feces

What infants mouthed

Mouthing episodes observed occurred while infant was on the ground and inside the house or inside the household yard

In-depth interviews Most caregivers reported seeing their infant eat soil

Five caregivers reported having seen their infant eat chicken feces

Two caregivers reported seeing their infant eat other animal feces

Some mothers believed that eating soil can help close the fontanel

An increasing number of mothers believed in the harm of eating:

soil < chicken feces < other animal feces

Results: Baseline n=30

Methods: The interventions

Commercial Community-built

Results: Describing use

“when he is outside he eats dirty, he even eat chicken droppings but when he is inside he does not eat all those, he plays very well”

“when he is playing from outside he can pick anything even animal waste because he is without reason but when he is inside there, he is safe, there is nothing dirty there”

“…when he is inside they stay together with his friends but when they are outside the friends go away and run away from him.”

“When he is in the play yard he sits down to play. When he is outside he moves a lot.”

Commercial Community-built

How did playard affect child’s exposure to soil and feces, regular movement, and interaction with other children?

Results: Describing use

Moved several times a day

Soap used to wash

Used as a play area

Frees caregiver time

“…once [the mother] puts the baby in the play yard, she can do a lot of chores while the child is playing…” [HH 21: Father]

Built in area close to house

Swept several times a day

Play areas and can protect child

May hinder work

"The only problem is that I always have to look into [the play yard] so much so that when I want to go to the field sometimes I am late… [HH 54]

Commercial Community built

Summary and conclusion

Both community-built and commercial protective play area acceptable and feasible to mothers

It is clear we need to re-think how we do WASH for the babies

Remaining questions Are interventions effective at reducing fecal exposure? How do we scale up and adapt to different contexts?

Safety – leaving babies unattended Balancing potential benefits of play space and child

development

Baby WASH Funding: David Atkinson Foundation

Acknowledgements• Rebecca Stoltzfus (Cornell)• Brie Reid (Cornell)• Gretel Pelto (Cornell)• Rie Seu (Cornell)• Jenny Orgle (CARE USA)• SHINE trial (Zimbabwe)• Modesta Chileshe and the

rest of the CARE Zambia team

• All the mothers who let us observe them and visit them numerous times!