T O M D A V I S , C H I E F P R O G R A M O F F I C E R , F E E D T H E C H I L D R E N

V A N E S S A T O B I N , S E N I O R T E C H N I C A L A D V I S E R , W A T E R S U P P L Y A N D

S A N I T A T I O N , C R S

C L E M E N T I N A N G I N A , F O O D & N U T R I T I O N M A N A G E R , F E E D T H E

C H I L D R E N , K E N Y A

REDUCING ENVIRONMENTAL ENTEROPATHY THROUGH INTEGRATION OF WASH AND NUTRITION

INTERVENTIONS IN CARE GROUP PROJECTS

IMPROVING WASH IMPROVES CHILD GROWTH

• Improved WASH is associated with an increase

of ~0.1-0.6 height-for-age Z-score (HAZ) about

the same effect size as the very best infant

feeding interventions

• “In areas with poor sanitation, children

experience vicious cycles of .. environmental

enteropathy. Emerging evidence links early

childhood diarrhea and/or growth failure with

an increased occurrence of risk factors for

cardiovascular disease in later life….”

[DeBoer, 2012]

ENVIRONMENTAL ENTEROPATHY

• Common change in

morphology of the gut in

developing countries: (1)

reduced surface area for

absorption and (2) more

permeable.

• Characterized by

increased intestinal

inflammation and

permeability, as well

(Prendergast & Kelly 2012)

Normal Env. Enteropathy

Visit Norway’s fjords!

ENVIRONMENTAL ENTEROPATHY

• Caused by chronic exposure to fecal bacteria in areas lacking sanitation and hygienic conditions (Prendergast & Kelly 2012)

• Environmental contamination EE

growth faltering (Lin et al. 2013)

• Chronic immune activation IGF-1

stunting AND Hepcidin anemia.

WHAT ARE CARE GROUPS?

• A community-based strategy for improving coverage and behavior change

• Developed by Dr. Pieter Ernst with World Relief/ Mozambique, used subsequently 27 organizations in 23 countries.

• Focuses on building teams of volunteer women who are selected by their peers, and represent, serve, and do health promotion with blocks of 10-15 households each

• “Pure” volunteers – no monetary incentives, just job aids

• Cost per case of malnutrition averted in one CG project was $26, about 15% of the average cost in one review of nutrition projects

www.CareGroupInfo.org

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

NGO/Country, Year

% of mothers with children 0-23 months who report

that they wash their hands with soap/ash

Baseline

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

NGO/Country, Year

% of mothers with children 0-23 months who report

that they wash their hands with soap/ash

Baseline

Endline

4. Safe disposal of adult and child feces

1. Clean Play Spaces

2. Wash hands with soap

before feeding the child

4. Safe disposal of adult and child feces

3. Treatment of drinking water before giving it to children

MAIN WASH BEHAVIORS FOR REDUCING ENVIRONMENTAL ENTEROPATHY

WAYS THAT WASH PRACTICES ARE IMPROVED IN CARE GROUP PROJECTS

• Hand washing with soap: • Increased through behavior promotion + encouraging families to

have a hand washing station including a Tippy Tap + Barrier Analysis to better understand barriers and enablers of the behavior.

• Increasing access to water treatment products: • A RCT by Food for the Hungry in Bolivia achieved a 79% reduction in

diarrhea by increasing access to hollow-fiber (Sawyer) filters and teaching people to use them through Care Groups.

• Other CG projects (e.g., Feed the Children / Malawi) have promoted P&G’s WaterGuard/PUR product for water treatment.

• Barrier Analysis – better understanding barriers and enablers of WASH behaviors

• Promotion of proper disposal of feces and use of latrines/potties. • “Baby WASH”: An emerging area – Especially having a clean play

area for infants and young children.

• Deworming • Multiple-micronutrient supplementation to reduce anemia and

impact of repeated infections

PROJECT PROGRESS

PROJECT PROGRESS

KIBERA CARE GROUP PROJECT

• Project area: 3 villages (Kambi Muru, Kisumu ndogo

& Lindi) in Kibera, Langata Sub County.

• Project target: pregnant women and mothers of

children <5 years.

• Project timeline: Jan 2015 – Jan 2018

• Result areas:

• Improved Essential Hygiene Actions

• Improved Essential Nutrition Actions

• Improved health care seeking; ANC, PNC and FP

Source: The nutritional value of toilets: How much international variation in child height can sanitation explain? Dean Spears, 2013

ADDRESSING EE

• Mothers and children over one years of age

should be treated for helminth infections and

receive multiple micro-nutrient supplementation,

• Mothers should ensure good hygiene practices focused on the young infant and for themselves

• Mothers should take up improved and hygienic infant and young child feeding practices.