Environmental Enteropathy and Baby Wash Testing community interventions to reduce infant fecal...
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Transcript of Environmental Enteropathy and Baby Wash Testing community interventions to reduce infant fecal...
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!