0. One Health Report for CARE Version 7 · risks of fecal exposure to children’s health and development. Education Modules. Education modules were modified from Zvitambo’s education

Report of The One Health Project for Nutrition at the Center CARE-Cornell

(Version 7)

CARE Zambia

One Health Report, CARE Zambia and Cornell University 2

August 7th, 2015

Prepared by members of the Community Engaged Nutrition Intervention Research Group at Cornell University

• Brie Reid

• Hope Craig

• Eliana Jacobson

• Rie Seu

• Lauren Jacobowitz

• Tatyana Roberts

• Katherine Kuang

With assistance from:

• Modesta Chileshe Zulu, CARE Zambia

• Catherine Pongolani, CARE Zambia

• Jennifer Orgle, CARE USA

This publication was made possible through the support provided by the Atkinson Center for a Sustainable Future at Cornell University. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the donors or CARE

Copies of the publication can be obtained from:

Rebecca Stoltzfus, CENTIR Group at Cornell University

[email protected]



Table of Contents Map of Zambia and Lundazi N@C District ............................................................................... 2 Acronyms ....................................................................................................................................... 4 Acknowledgement ......................................................................................................................... 5 Executive Summary ...................................................................................................................... 1

Results & Recommendations ................................................................................................................ 3 Introduction ................................................................................................................................... 5

Study Area Location ............................................................................................................................... 5 Background on the One Health Pilot Project ....................................................................................... 5

Methods .......................................................................................................................................... 7 Overview .................................................................................................................................................. 7 Sampling Strategy ................................................................................................................................. 7 Study team organization ..................................................................................................................... 9 Ethical considerations ........................................................................................................................ 10

Baseline Methods ........................................................................................................................ 10 Baseline content ................................................................................................................................. 10 Baseline field team formation and training ................................................................................. 11 Baseline data management .............................................................................................................. 12 Baseline Challenges ............................................................................................................................ 12

Education Module Overview ..................................................................................................... 13 TIPs Methods .............................................................................................................................. 14

TIPs content ......................................................................................................................................... 15 Visit 1 .................................................................................................................................................. 15 Visit 2 .................................................................................................................................................. 16 Visit 3 .................................................................................................................................................. 16

TIPs field team formation and training .............................................................................................. 16 TIPs data management ......................................................................................................................... 16

Data Collection. .................................................................................................................................. 16 Data Entry. .......................................................................................................................................... 17 Data Analysis. ..................................................................................................................................... 17

TIPs Challenges .................................................................................................................................... 18 Baseline Results ........................................................................................................................... 18

Household Characteristics ................................................................................................................ 18 Water Access ........................................................................................................................................ 20 Household Hygiene Characteristics ................................................................................................ 21

Caregivers’ WASH practices & beliefs. ............................................................................................. 21 Infant mouthing behaviors & geophagy .............................................................................................. 23 Animal Presence in the Household ..................................................................................................... 27

TIPs Visit 1 Results ..................................................................................................................... 28 Household Characteristics ................................................................................................................... 28

Caregiver & infant development ......................................................................................................... 28 Household hygiene characteristics ...................................................................................................... 29 Baby WASH Behaviors & Knowledge ............................................................................................... 30 Caregiver attitudes towards infants eating soil/feces .......................................................................... 37


TIPs 2 & 3 Observation Results ................................................................................................ 42 24-Hour Recall Results ............................................................................................................... 46 TIPs Interviews ........................................................................................................................... 54 TIPs Counseling Session ............................................................................................................. 61 Insights and Recommendations ................................................................................................. 62

Baseline ............................................................................................................................................... 62 Education Module ............................................................................................................................... 64

Appendix ...................................................................................................................................... 69 1.1. Nutrition at the Center, Results Framework .................................................................... 72 Context in Images ............................................................................................................................... 73

Map of Zambia and Lundazi N@C District



Acronyms

ANC Antenatal Care

Baby WASH Water, Sanitation, & Hygiene interventions specifically for infants and toddlers

CENTIR Group Community Engaged Nutrition Intervention Research Group (at Cornell University)

EE (EED) Environmental Enteropathy (Environmental Enteric Dysfunction)

HWWS Hand washing with soap

IYCF Infant Young Child Feeding

N@C Nutrition at the Center

SHINE Sanitation, Hygiene, Infant Nutrition Efficacy Project in Zimbabwe

TIPs Trials of Improved Practices

WASH Water, Sanitation, & Hygiene

Zvitambo Zimbabwean research organization conducting the SHINE trial


Acknowledgement First and foremost, we are grateful to the women who readily consented to participate in this

study and approved their young children’s enrollment. The women provided their valuable time and candidly shared their personal experiences. We are also grateful to the community health centers and the village leaders for their support, the community health volunteers for introducing education modules to nutrition support groups, and the communities that welcomed this pilot study into their daily lives and activities.

The study team extends sincere appreciation to CARE HQ team including Jennifer Orgle and Khrist Roy who have supported our team on the integration of this pilot study to Nutrition @ the Center work. Our work would not have been possible without the assistance of the following colleagues in CARE Zambia: Dennis O’Brien, Oliver Wakelin, Catherine Pongolani, Modesta Chileshe, Paul Chipopa, and Joseph Mumba. Their expertise from technical matters, sorting out logistic and other challenges, and their coordination of training and data was invaluable every step of the way. We are also thankful to countless CARE colleagues for facilitating communications and liaison with government sector offices in the study areas. Our thanks goes to the survey field staff (enumerators, supervisors, data entrants and drivers) who agreed to function collectively as a team despite the challenges experienced during demanding field research and implementation.

The study team also extends our thanks to the wonderful researchers at Cornell University and the many talented researchers with Zvitambo, working on the SHINE trial in Zimbabwe. Along with countless others, we thank Rebecca Stoltzfus for her research expertise and vision, Gretel Pelto for her advice on textual analysis of interviews, and Kate Dicken for her knowledge and troubleshooting help with the modified TIPs protocol. We also thank Dadirai Fundira, Cynthia Matare, and Rukundo Kambarami for sharing their community-engaged intervention experience, Sarah Dumas for her in-country assistance, and Francis Ngure for his seminal work on Baby WASH and his help with baby mouthing observation protocol.

The One Health for Babies and Livestock project was generously supported by a grant from the Atkinson Center for a Sustainable Future at Cornell University. We wish to thank Wendy Wolford at Cornell and Tonya Rawe at CARE USA for their stewardship of the CARE-Cornell partnership and their guidance throughout the project.


Executive Summary Introduction

The One Health for Babies and Livestock project is a pilot study of two play-yard based Baby WASH interventions (a commercial, western plastic play yard and a mud-brick/traditional materials community built play yard) intended to protect children from the dangers of fecal contamination in their environment. Baby WASH, or water, sanitation, and hygiene interventions developed to interrupt the unique fecal-oral route linked to a child’s early developmental stages, has been recommended to protect infants under 24 months.1 The study was conducted in intervention sites of CARE Zambia’s Nutrition at the Center (N@C) program, which is designed to improve the nutritional status of women (15-49) and children less than 2 years of age in the Lundazi and Chadiza districts of the Eastern Province in Zambia. The One Health project explores household adaptation of infant-specific water, sanitation, and hygiene interventions to address the unique fecal-oral route from contaminated floors, soil, and chicken feces experienced by a crawling and toddling child in low-income countries2.This report is compiled based on the One Health for Babies & Livestock Pilot Study conducted in 6 intervention-designated villages within the Lundazi district from November 15th 2014 to July 15th 2015.

Methodology. The One Health study consisted of three distinct phases: a baseline observational study and

survey, delivery of an experimental education module to community groups, and a series of pilot studies with play yards, modified from trials-of-improved practices (TIPs),3 that tested the acceptability and feasibility of a commercial play yard and a community-designed play yard intervention to separate crawling and toddling infants from feces and contaminated soil in their environment.

The research team at CARE Zambia identified and invited 6 villages from 4 health center catchment areas to participate in the One Health project, based on their (1) Proximity to the CARE office, (2) Representativeness (similarity to other communities in the area), (3) Agreement of the community leader to participate and support the research, and (4) availability of infants and toddlers within the village. The team at CARE Zambia then worked with community leadership to sensitize and involve community members by hosting a community meeting with headmen of each village. The community meetings consisted of:

1. The community leader introduced the research team and indicated support of the activities. 2. The research team provided an overview of the entire project and why it is important – how it

may help children and families. 3. The community leader reiterated support and helped identify the young men and women from the

community who had completed secondary school and would be able to help the research team by conducting surveys and observations.

1 Ngure, Francis M., et al. "Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links." Annals of the New York Academy of Sciences 1308.1 (2014): 118-128. 2Ngure, Francis M., et al. "Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria." The American journal of tropical medicine and hygiene 89.4 (2013): 709-716. 3 Dickin K, Griffiths M, Piwoz E. Designing by dialogue: a program planners' guide to consultative research for improving young child feeding. Academy for Educational Development. Support for analysis and research in Africa (SARA), 1997.


4. Families with free-range small livestock and children 3-24 months old were invited to participate in the pilot study. Households who were interested set up appointments for researchers to come to their home to administer the survey and observations.

Baseline At the first visit to the household, researchers reviewed the study, risks, and obtained oral

consent. 30 households were surveyed for demographics, feeding, childcare, animal husbandry, and sanitation and hygiene practices. Community members who had completed secondary school were recruited and trained to perform an observational study to characterize the location of infants and animals in households and the community, exposure to fecal material and infant hand-to-mouth behaviors. Insights from the baseline survey and observations were used to edit existing educational modules on the risks of fecal exposure to children’s health and development.

Education Modules. Education modules were modified from Zvitambo’s education modules in the Sanitation, Hygiene,

Infant Nutrition Efficacy (SHINE) Project in Zimbabwe, to fit the community support group model of education dissemination practiced by N@C at CARE Zambia. There are 5 key messages that were distilled from multiple visits in SHINE to 1 visit in the One Health project, listed below. These messages were then edited with input from Cornell University, CARE USA, and CARE Zambia to reflect the baseline observations and the specific country context.

1. Dispose of all feces in latrine; including children’s feces.

2. Wash hands with soap (or ash) after fecal contact and before preparing, eating or feeding food.

3. Put baby in clean, protected area where he/she cannot access dirt/ feces when playing or eating and do not let baby eat feces or soil.

4. Treat drinking water and give treated water to children over 6 months.

5. Feed baby freshly prepared or reheated food.

Trials of Improved Practices (TIPs) 24 families who participated in the baseline with children 6-24 months of age were invited to consent

to participate in the TIPs data collection, which over the course of three weeks followed the protocol of:

1. Visit 1 – Deliver commercial play yard (3 villages) or community play yard4 (3 villages) and obtain consent.5 Observation of play-yard related WASH behaviors and an interview to assess caregiver’s knowledge of education modules were conducted.

2. Visit 2 – With a structured questionnaire, a semi-structured interview, a 24-hour recall of play yard use, observation, and a counseling session, researchers probed experiences, assessed implementation of new practices, reminded the caregiver of key WASH messages, and renegotiated revisions to the potentially harmful practices if necessary.

4 Community play yard will be a play yard designed and constructed in each household with traditional architectural methods (mud brick walls, open air, thatched roof). See file “TIPs community play yard mock up.pdf” for details. 5 Households will have the option of keeping the play yard/community design solution at the conclusion of the One Health Project Pilot Study.


3. Visit 3 - final assessment was conducted (interviews & observations) to assess acceptability, adherence, adaptations, and behavioral outcomes for animals, babies and their caregivers.

For communities selected to receive a community-designed play yard, CARE staff facilitated a participatory co-design session with the village leaders and community members.6 Community members and village leaders will be encouraged to recruit local craftspeople and use local skills, identify opportunities and risks of design, and ensure groups are representative of the community with special attention to gender parity. With the final design, the CARE staff members then will take pictures and create drawings to communicate the design to the families designated to receive the community-designed solution.

Results & Recommendations

Baseline In the baseline observation and survey of 30 households with infants/toddlers and free-range

livestock, we observed incidences of open defecation despite the presence of latrines, yards that contained chicken and human feces, many free range livestock moving through the area in which the child plays, and a third of households had chicken feces visible on the kitchen floor upon arrival. Just less than half of caregivers reported using unprotected water sources as their primary sources, a number of caregivers reported using dirty dishwater to wash their hands, and soap was primarily used for washing clothes/people’s bodies and infrequently used to wash hands.

Most caregivers reported having seen their infant eating soil, and 5 caregivers reported having seen their infant eat chicken feces. Only 2 caregivers reported having seen their infant eat other animal feces. Although a many caregivers said that eating soil or feces causes illness/diarrhea, stomachache, and/or worms, a small but concerning minority of caregivers reported that eating soil was associated with closing the fontanel and helps the baby’s guts/intestines. The caregivers who reported perceived benefits of eating soil/feces also reported a number of negative consequences of eating soil/feces, indicating either some confusion about the consequences of eating soil/feces on the part of the caregivers or indicating a more nuanced belief system of the consequences of eating soil/feces than the free-response survey was able to capture. During the observation of infant mouthing activities, infants’ hands were frequently mouthed in most households and were observed as visibly dirt 74% of the time. Toys/play things were visibly dirty during 80% of mouthing occasions, and siblings were mouthed and visibly dirty on 93% of mouthing occasions. Infants were observed mouthing soil/stones, sticks, and animal feces during the time of observation. Education modules were edited to educate mothers on mouthing behaviors and the danger of infants ingesting soil and feces.

Trials of Improved Practices

Mouthing Behaviors and Babies’ Experiences with Play Yards Babies were not mouthing soil while in the play yards but started mouthing items while outside the

play yard. In most instances, caregivers were stopping the babies from mouthing dirty items while researchers were observing. Keeping a clean environment for the baby to help the baby grow and to reduce illness was a salient belief among caregivers and their immediate family. A few caregivers noted that the play yard was beneficial as it keeps the baby cleaner for longer. Even after education modules, caregivers noted that they believe eating soil is good for the baby’s guts/intestines, and a few caregivers mentioned that neighbors also believe that geophagy is good for the baby’s guts/intestines. These deeply

6 Note: for the winning community solution, an amendment to the Cornell IRB was submitted to include possible safety hazards from the community solution, and ways to mitigate those safety hazards identified.


held beliefs will need further study and community outreach to both understand the underpinnings of the perceived benefits of eating soil and change communities’ perceptions of babies eating soil.

Entertaining babies while in the play yard was identified as a challenge by caregivers. Babies enjoyed being in the play yard as long as other children or siblings were there. Only a few households had given some sort of toy to the baby, making it difficult to play alone. A few caregivers noted that the baby plays with many more children outside of the play yard and plays with much fewer children when inside the play yard. Siblings are often supervising and interacting with crawling and toddling infants, and thus interaction between infants and siblings in this context should be explored further. Future education interventions could include siblings of young children and encourage siblings to also keep their baby brother/sister from eating soil/feces.

Caregiver’s Experience with the Play Yards and Baby WASH Even though a number of caregivers still reported believing that eating soil helps a baby’s

guts/intestines, the WASH practices had greatly improved in most of the households. The yards were swept upon arrival and most households had managed to build latrines with hand washing facilities. Although a few caregivers shared that the play yard allows them to more easily do their chores, the Baby WASH intervention still adds more activities to a caregiver’s day, and more exploration is needed to determine if the play yard intervention saves a caregiver time. Seasonality, both during harvest seasons and dry seasons, appears to play a large role in the ability of caregivers to practice Baby WASH. For example, during the dry season water scarcity was an issue and during harvest season, caregivers typically only used the play yard once a day in the morning before going out to the fields for the rest of the day.

A number of caregivers, when asked about keeping a clean environment for their infant, mentioned strategies associated with reducing the risk of malaria and breeding mosquitos in the household. Future education modules can incorporate both malaria messages and Baby WASH messages to present a more cohesive strategy to keep a clean environment for a growing baby. Additionally, integrating fecal disposal messages into gardening educational modules can further strengthen the practice of taking feces out of the household yard and using animal feces as manure in the garden.

As expected, baby hand washing was still a challenge for most caretakers. Additionally, a few caregivers mentioned difficulty in building/setting up the play yard, reported taking much more time to wash the mat and play yard, and expressed difficulty in using so much soap when it is not easy to replace. Even during the winter and out of the dry season, caregivers still reported using dirty dishwater to wash their hands. One caregiver also expressed dissatisfaction about washing her hands after using the toilet and disposing of dirty laundry water at the far edge of the household yard. Future education modules on gardening could position dirty laundry/dish water as good water to use on the household garden rather than using it for hand washing or letting that water go to waste, if deemed appropriate by CARE intervention staff. In any case, water scarcity and access is a key issue in these communities if they are to practice the most effective WASH practices.

Community Reactions There was a lot of cooperation with health center staff and traditional leadership throughout the

research process and during the building phase the community members seem to have accepted the traditional play shelters (evidenced by two families outside of the selected participant households who pleaded with community members to have play shelters built for them). However, during interviews participating caregivers mentioned negative opinions, judgment, and mockery about the play yards from other neighbors and other caregivers. Negative opinions from outside of the family included neighbors thinking that the play yard/mat is a waste of both time and soap, neighbors not seeing the benefits of the play yard/mat, and neighbors wondering how the child will grow if the child is in the play yard. Some of the participating caregivers noted that these negative opinions are due to jealousy, and caregivers reported not being affected by the negative opinions of neighbors.


Introduction Study Area Location

The One Health Pilot Study for Nutrition at the Center (N@C) was conducted in 6 intervention villages spread amongst 4 health center catchment areas in the Lundazi District of the Eastern Province of Zambia. Control villages were included due to the exploratory and small-scale design of the project.

Lundazi is isolated from the nearest large town, Chipata, by 170 km of paved road. The rural landscape is mostly cleared of trees for subsistence farming and cattle-raising. The region is prone to flooding and food insecurity, especially in January, the month of highest rainfall. In the villages there is no electricity, running water or waste disposal system. In general, villages consist of one zone that is comprised primarily of multiple homesteads and support structures and a secondary zone comprised of fields with crops. The Tumbuka is a patrilineal tribe in which community roles are defined by gender and polygamy is widely practiced. Although the legal age of marriage in Zambia is 18, early marriages in the Lundazi district are common.

Households consisted of two or more traditional mud or brick-walled houses with grass-thatched roofs as well as a few auxiliary shade or storage structures constructed of wood and reeds. The immediate household yard and kitchen area were open yards with bare, loose sandy soil without a fence to separate one household from another. Infants were free to crawl on bare soil where poultry and other animals were free to roam.

Background on the One Health Pilot Project The One Health project is a pilot study nested within Nutrition at the Center (N@C), a multi-

sectoral project of CARE Zambia designed to improve the nutritional status of women (15-49) and children less than 2 years of age in the Lundazi and Chadiza districts of the Eastern Province. The project plans to impact nutrition-related behaviors, increase utilization of maternal and child health and nutrition services, increase household adaptation of appropriate hygienic and sanitation practices and increase availability and equitability of access to nutrient-dense food.

Rural families face daily challenges to their health and well-being. In Sub-Saharan Africa, about one-third of babies do not grow to their full genetic potential due to a combination of environmental and nutritional challenges, many of which result in chronic stunting and anemia. Childhood stunting and anemia are associated with impaired cognitive development, poor school performance, reduced lifetime earnings and the perpetuation of the intergenerational cycle of poverty. While stunting and anemia are linked to food insecurity, they are not adequately addressed by dietary interventions alone.

Environmental Enteropathy (EE), a subclinical infection of the gut, is an invisible condition thought to be responsible for a significant proportion of childhood malnutrition. Several studies found EE to be nearly universal in infants and have attributed 43-60% of stunting in African children to this condition. Young children suffer from environmental enteropathy when their home and play environments are contaminated with bacteria from human and animal feces. Traditional water, sanitation, and hygiene interventions (such as latrines or hand-washing) protect adults from bacterial exposure but do not address exposure for young children. Infants and toddlers ingest a substantial amount of contaminated soil through crawling and exploring their environment with their hands and mouths. Thus, new


approaches are needed to protect developing children from the risk of human and animal fecal contamination.

The “One Health for Babies and Livestock” project aims to protect children’s growth and development while maintaining the benefits that small livestock provide for rural farming families. The project brings together nutrition experts, livestock experts, designers, and community members in Zambia to collaboratively create a solution for environmental enteropathy that works for both children and their families. The results from this project will help shape future interventions for environmental enteropathy in ongoing CARE and Cornell nutrition programs.

The One Health project arose from a collegial relationship between Benjamin Schwartz and Ann Digirolamo (formerly at CARE USA) and Dr. Rebecca Stoltzfus at Cornell University. Based on emerging research and hypotheses around the links between childhood stunting and WASH, both parties recognized that smallholder-farming families both reap the benefits that small livestock provide and also face challenges to provide their young children with safe environments for development. Motivated both by the importance of finding solutions for this global problem and also by ongoing program needs, CARE USA and Cornell University sought to explore acceptability and feasibility of a Baby WASH intervention that local communities could implement with minimal cost and maximum sustainability. With funding from the Atkinson Center for a Sustainable Future at Cornell University, Cornell University partnered with CARE USA and CARE Zambia to pilot an exploratory Baby WASH intervention in N@C communities in rural Zambia with the intention to scale up a successful intervention both throughout N@C in Zambia and in the N@C countries of Benin, Bangladesh, and Ethiopia.

Mission: Address a key challenge faced by smallholder farmers and the rural poor: animals are important to families’ well-being and resiliency but fecal exposure creates substantial risks for infants and young children.

Vision CARE is implementing Nutrition at the Center (N@C), an integrated program to improve maternal, infant and young child nutrition in Zambia, Ethiopia, Benin and Bangladesh. And Cornell is a partner in the large-scale community-based SHINE Trial researching approaches to prevent EE in Zimbabwe. Thus, results from this work will contribute to the success of ongoing CARE and Cornell programs, contribute to progress addressing a key global challenge, and increase recognition of CARE and Cornell by donors and other stakeholders who are increasingly interested in EE.

Objectives 1. Use community-based design approaches to develop technologies and behavior change

communications to reduce risk of fecal exposure and EE among young children; 2. Test the feasibility, acceptability, and effectiveness of potential strategies using outcome

measures that include both animal husbandry and child care practices. 3. Provide input to CARE’s N@C program and the SHINE Trial, for contextualization and

implementation through those programs, and share learning globally.


Methods Overview The baseline study applied a multi-phase, cross-sectional observational, survey, and in-depth interview method. Study structure diagrammed below.

Figure 2. One Health Phase & Milestone Diagram

Sampling Strategy For the baseline survey and observation, 30 households from six villages with infants distributed

across five different age groups (3 infants between 3 to <6 months, 8 infants from 6 to <9 months, 8 infants from 9 to <12 months, 9 infants from 12 to <18 months, and 2 infants from 18 to <24 months) were purposively selected from 4 health center catchment areas within N@C’s intervention villages. We recruited households for the duration of the whole project to provide a longitudinal view of fecal-oral pathways at the household level, and track how behaviors/motivation for Baby WASH change.

Community Selection Criteria: • Representativeness (i.e. similarity to other communities in the area) • Proximity to CARE office


• Available babies to survey and observe • Agreement of the community leader to participate and support the research.

Villages were purposively selected based on their ease of access by road, proximity to health

center, and size. Villages were selected if they were within a 2-hour drive by car from the Lundazi district office, were a typical medium-to-large village based on health center census data, and were not adjacent to a health center. 6 villages were selected so that 3 villages to receive the plastic PY intervention would be separate enough from the 3 community PY intervention villages as to not cross-contaminate intervention pilot studies and provide enough caregiver-infant pairs to participate in the One Health study.

Selection criteria for households included a household with free-range livestock and an infant between 3 – 24 months of age for the baseline survey. 30 households with infants in 5 separate age categories (3 to <6 mo., 6 to <9 mo., 9 to < 12mo., 12 to <18 mo., and 18 to <24 mo.) were sampled for the baseline to include a wide range of gross motor development stages. Infants between the ages of 6 to <18 months were oversampled as those ages are the target age ranges for Baby WASH interventions. The age ranges have been selected in order to capture major motor development milestones in infancy and early childhood and to characterize different risks of fecal contamination at different developmental stages:

• 3 to < 6 months (laying, rolling, sitting without support) • 6 to < 9 months (sitting without support, hands-and-knees crawling, standing with assistance) • 9 to < 12 months (standing with assistance, walking with assistance, standing alone) • 12 to < 18 months (walking alone) • 18 to < 24 months (confident walkers)

Figure 1. Motor milestone achievement in months7

7 from Onis, M. (2006). WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatrica, 95(S450), 86-95.


In the TIPs phase of the project, 24 infants were recruited between 6 – 24 months of age (12

infants per intervention arm). The age groups of these infants were 9 to <12 mo., 12 to <18 mo., and 18 to <24 mo. to compare the acceptability and feasibility of a community PY or plastic PY for caregivers in this context. 2 caregivers dropped out of the TIPs segment of the study due to moving away to Malawi or being uninterested in participating past the baseline survey, leaving 21 infants to participate in the TIPs visits (10 infants in the community-built play yard arm, 11 infants in the commercial play yard arm).

Figure 3: Study Participant Flow Diagram

Study team organization The staff involved in this study is grouped into a core team, a field team, and a data management

team. The core team leadership consisted of the CARE USA Program Director of Nutrition at the Center, the Project Manager of Nutrition at the Center at CARE Zambia, and a faculty member in international nutrition and intervention implementation from Cornell University. The core team implementation manager included a Baby WASH research specialist from Cornell University and the CARE Zambia Development Coordinator-EE. The field team from CARE Zambia included an enumeration team and were supervised by the Development Coordinator-EE from CARE Zambia who was stationed in the district office. The data management team consisted of 7 data analysts and 4 data entrants from Cornell University and were managed by the Baby WASH specialist. The following chart shows the study team organization.

Figure 4: One Health Team Organization

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

Project PIs (3)

CARE USA PI (1)

CARE Zambia PI (1) Development Coordinator-EE Enumerators (4)

Cornell PI (1) Project manager & coordinator

Data analysts (7)

Data enterants (4)


Ethical considerations Prior to beginning the study, CARE Zambia was granted ethical clearance from the local Zambian ethics review board under N@C ethics approval and Cornell University was granted ethical approval by the Cornell University Institutional Review Board (IRB).

Baseline

A standard oral consent form preceded the questionnaire and observation.8 The interview was preceded with reading out the consent statement to and seeking verbal consent from the respondent caregivers. Prior to the survey, CARE Zambia was granted ethical clearance from the local Zambian ethics review board under N@C’s ethics approval and Cornell University was granted ethical approval by the Cornell University Institutional Review Board (IRB) under the Nutrition at the Center Program.

TIPs

The TIPs component of the study introduced a second oral consent form that again introduced the study and risks, especially the specific risks of trying out one of the play yards (plastic or community-made). The interview was preceded with reading out the consent statement to and seeking verbal consent from the respondent caregivers. As with the baseline consent form, Prior CARE Zambia was granted ethical clearance from local Zambian ethics review board under the Nutrition at the Center Program and Cornell University was granted ethical approval by the Cornell University Institutional Review Board (IRB).

Baseline Methods Baseline content The One Health Baseline consisted of three parts: an infant mouthing observation, a household hygiene and animal presence observation, and a survey of household WASH behaviors and beliefs. After obtaining consent, one enumerator followed the infant of the household for ~6 hours and conducted the infant mouthing observation from Francis Ngure’s seminal work on infant mouthing behaviors9. Concurrently, a second enumerator conducted spot checks of household hygiene and hand-washing practices. The infant mouthing observation was conducted before the survey questionnaire as to not impact the caregiver’s behavior regarding WASH practices and infant geophagy interference (Part 1A). At the end of the observation, the survey is an opportunity to bring biscuits & soda in order to make a social moment in the afternoon to talk with the caregiver. The survey MUST come after the observation because otherwise the survey could change the caregiver’s regular activities.10 The infant mouthing observation was organized into 7 modules ranging from 1A.A to 1A.G:

• Infant development observation

8 Due to the lack of literacy and the oral consent process, the Cornell IRB required a witness, who was a person independent of the research team and could not be unfairly influenced by people involved with the research, who does not have a coercive relationship with the participant, and who attends the informed consent process, to sign the oral consent form. A translator who participated in the informed consent process may serve as the witness. 9 Ngure, Francis M., et al. "Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria." The American journal of tropical medicine and hygiene 89.4 (2013): 709-716. 10 For more details, see files “1. Baseline Baby Observation Form”, “1. Baseline HH WASH and animal Observation Form”, and “1. Baseline survey form”


• Infant mouthing observation • Infant feeding episodes • Caregiver hand-washing opportunities • Infant hand-washing occurrences • Disposal of nappies after defecation • Observer comments & notes

The household WASH observation (Part 1B) was organized into 3 time points of observation: upon arrival, at noon, and in the afternoon/end of interview. The types of observation conducted included:

• Types of animals present, indicate corralled or not corralled • Types of feces present – animals • Human feces present • Diagram of the household, with indicators of feces and animal presence • Observer comments & notes

The survey questionnaire (Part 2) was originally designed by Zvitambo and was modified by Cornell University based on the pilot study’s needs. It was then refined from rounds of feedback from CARE USA, CARE Zambia, Cornell University, and Zvitambo collaborators. It contained questions organized into 7 sections ranging from A to F, with an additional X section. The CARE Zambia field team conducted translation of the questions from English to Tumbuka. The questionnaire consists of the coded letters on the left side and the skip pattern guides on the right side.

Baseline Questionnaire Categories

• Screening questions and consent • Section A: household identification, interview information • Section B: household composition, literacy • Section C: early childhood development (based on MICs) • Section D: caregiver’s WASH knowledge and beliefs, self-reported soil eating practices

(geophagy) • Section E: household sanitation & hygiene practices • Section F: animal husbandry practices • Section X: general household observations

Baseline field team formation and training The field supervisor, data collection, entry and quality control staff were recruited from local

community health centers and village headmen. The recruitment and selection process was undertaken in consultation with CARE field office in Lundazi, the local health center staff, and village headmen. A total of 4 persons were brought on board for training. A schedule for training of supervisors and enumerators was designed by the Cornell University and CARE Zambia team jointly.

The training began with provision of background information on the One Health project and objectives of the baseline survey, spent 2 days discussing the questionnaire line-by-line and one day on field survey methodology. CARE Zambia staff facilitated the training sessions.

The final day of the training, field simulation exercise took place to field test the questionnaire. This session shed light on the unforeseen possible logistic challenges and helped to uncover some insights on best possible ways of making the field arrangement. The standardization exercise helped to identify


enumerators’ individual differences in baby observation.

Baseline data management

Data collection. The village headmen who had attended the EE sensitization meeting informed the community

members about the study and the research team was well-received in all of the six villages, though some communities were more receptive than others. In accordance with the field data collection arrangement and team movement plan, developed by Cornell University and adjusted per CARE’s feedback, the entire field team conducted data collection from 5th to 23rd December 2014. There was a break in-between due to a planning meeting held in Chipata. The study was conducted by 4 enumerators from the targeted villages and was supervised by the Development Coordinator-EE. It was not possible to include women as research assistants because the study team could not find any qualified woman in the four villages.

The enumerators were organized to work in pairs and would periodically be accompanied by the field supervisor. The pairs were guided to do interview and baby observation measurement alternatively so they would share the workload fairly. The supervisor supported the pair in locating households. When the pair went into a house, they first checked if the women and children in the households met inclusion criteria, then requested for consent, began with the baby and household observation tools and finally conducted an interview with the caregiver.

Each pair was given one set of questionnaires and observation tools per household. During the data collection, the supervisor moved from one pair to another to check for compliance of the enumerators to inclusion criteria, consent, interview techniques, and observation procedures and provided on spot feedback. At the end of the day, all enumerators met at a central place and handed over the completed questionnaire. The supervisor checked each questionnaire received, confirmed compliance, and discussed the visit with enumerators. The supervisor digitally scanned the questionnaire. Due to internet connectivity issues and large file sizes of the scanned booklets, the booklet files were brought to Cornell physically by a member of the research team. The Cornell University project manager supervised data entry and digitization in Ithaca, NY.

Data Entry. A double entry protocol was followed in this survey. The data entry template was developed by

Cornell University using the Cornell Qualtrics web survey tool. The Cornell project manager recruited and trained 4 data entrants in Ithaca, NY to carry out the data entry in Ithaca, NY. To ensure quality of data, every questionnaire was spot-checked for consistency. When deviations between data entrants were identified, the team went back to the digitally scanned questionnaire and corrected the mistakes.

Data Analysis. Dummy tables were designed by Cornell initially based on the study objectives, survey questions

and possible relationships of the variables under study. The data analysis team applied descriptive statistics to present the findings of this study. The data analysis was undertaken with Microsoft Office Excel 2011.

Baseline Challenges Similar to any other surveys conducted in rural areas, poor road infrastructure, issues with electric power supply access, and access to competent field workers were key field work challenges throughout the course of the One Health Baseline and TIPs phases. For the sake of documenting lessons we have reported the key challenges we faced in the course of this study as follows.


1. Fortunately for data collection, the rains were one month late. However, observing babies in the household was very challenging when the rains started. The rains were heavy the last two days of the research and teams had to wait for about 2- 3 hours before starting the observations. During the rains, the space for observation was limited, as everyone had to remain indoors. The rains washed some animal feces away so the observations on these days do not give an accurate version of what was prevailing in the yard.

2. The data assistants worked in pairs had to travel long distances each day to and fro fieldwork sites. The lack of proximity to the four health centers required more than one supervisor per day in order to supervise both pairs of enumerators every day. However, the budget could not afford an extra supervisor to monitor both teams on a daily basis and thus the coordinator monitored the two teams of research assistants on alternate days.

3. Although the babies were easily available in all the villages, it was a challenge to find babies less than 6 months old.

4. It was also challenging to find households with animals and poultry. Baseline observations began during the period when Newcastle disease wipes out poultry, and animals die of various infections. Even though some babies included had no animals at their homes, animals from neighbors passed through and left feces on the homestead.

5. The baby mouthing charts were clear and easy to fill out but it was challenging to follow and track everything the baby mouthed when the baby was on the move. Toddlers and babies able to walk independently were especially challenging to follow.

6. Seasonal heavy rains resulted in power outages and corresponding internet connectivity issues when the field research team in eastern Zambia attempted to send digital copies of completed booklets to the data analysis team in Ithaca, NY. The scanned booklets from field enumerators were too large to send securely over the spotty internet connection and therefore had to be hand-delivered from Zambia to Cornell University by a member of the research team who happened to be in Zambia doing fieldwork on another project. Future research projects should plan for internet connectivity issues in the field offices of Chipata and Lundazi and ensure that data files are compressed enough to send securely to research partners overseas.

Education Module Overview Education modules were modified from Zvitambo’s education modules in the Sanitation, Hygiene,

Infant Nutrition Efficacy (SHINE) Project in Zimbabwe, to fit the nutritional support group model of education dissemination practiced by N@C at CARE Zambia. The modules were delivered by a subset of trained community health volunteers during the course of a month (one meeting out of the two meetings per month). There are 5 key messages that were distilled from multiple visits in SHINE to 1 visit in the One Health project:

1. Dispose of all feces in latrine; including children’s feces.

2. Wash hands with soap (or ash) after fecal contact and before preparing, eating or feeding food.

3. Put baby in clean, protected area where he cannot access dirt/ feces when playing or eating and do not let baby eat feces or soil.

4. Treat drinking water with Water Guard and give treated water to children over 6 months.

5. Feed baby freshly prepared or reheated food.


These messages were then edited with input from Cornell University, CARE USA, and CARE Zambia to reflect the baseline observations and the specific country context. All modules are interactive and caregivers are encouraged to participate in the activities and ask questions at anytime. Volunteer educators were encouraged to write down any questions that come up for caregivers in the nutrition support groups, and report those questions back to CARE-EE staff. The following table reviews the objectives and corresponding activities.11

Table 1. Education Modules: Objectives and Activities

Objectives Activity

Identify the hazards of current practices, dirty soil, and improper fecal disposal

Flagging stools: mark feces in the household to show widespread contamination.

Increase the adoption of latrine use, hand washing, yard sweeping, and separation of baby and animals.

Keeping a clean home: review how to keep household free of fecal bacteria.

Separate infants from animals List and map animals close to home/baby: Use animal, field, and baby cards.

Improve the recall of fecal disposal practices Round up discussion

Figure 5: Group participates in animal and baby mapping activity, March 2015

Figure 6: Detail of animal and baby mapping cards, March 2015

TIPs Methods

11 For more details, see file “2. Education CARE N@C Baby WASH modules.docx”, “2. Education fecal oral route a4.pdf”, and “2. Education cards animal activity 2.pdf”


TIPs content The Trials of Improved Practices (TIPs) phase split the 6 villages in half, so that households in 3

villages would receive the community play yard intervention and households in the other 3 villages would receive the plastic play yard intervention. The villages were split based on proximity, such that the community play yard villages would be far enough away from the plastic play yard villages to ensure that the different intervention villages would not influence each other.12 After either building the community play yard and delivering the mat or delivering the plastic play yard and mat to households, the TIPs consisted of three visits per household, conducted 1 week apart. These visits included household hygiene spot check observations, interviews with caregivers to assess Baby WASH knowledge and practices, a review of Baby WASH education module, 24-hour recall of play yard use, in-depth interviews, and an abbreviated infant mouthing observation.

Plastic play yard intervention, with mat made from stitched-together grain bags

Community-build play yard intervention. Not shown: mat made from stitched-together grain bags, images of animals painted on inside walls

Visit 1 • Consent • Survey of background characteristics (infant age, developmental milestone achievement,

caregiver relationship & time away from infant) • Observation of household hygiene • Survey of Baby WASH knowledge, beliefs, & N@C nutrition support group attendance • Review of Baby WASH education module • Delivery of plastic play yard and review of safety concerns (community-built PY was constructed

1-3 weeks prior to visit 1) • Semi-structured short interview on caregivers’ initial reactions to PY

12 The plastic play yard intervention was selected to compare to the community-built play yard intervention in order to compare the results to Zvitambo’s SHINE Trial TIPs on plastic play yards in Zimbabwe and also shed light on potential issues with the community play yard (e.g. do caregivers reject the community play yard AND the plastic play yard because it is culturally unacceptable, or do caregivers reject the community play yard based on design deficiencies?).


Visit 2 • Observation of household hygiene and PY • In-depth interview on PY use • 24-hour recall of PY use (Each episode of play space use was analyzed to understand, duration of

play space use, motivators for use) • Identification of safety hazards and counseling on safe/proper PY use

Visit 3 • Observation of household hygiene and PY • 24-hour recall of PY use • Review of counseling on safe/proper PY use

• Baby mouthing observation of soil, stones, sticks, and feces in and outside of PY.

TIPs field team formation and training The same 4 field enumerators were kept for the TIPs phase of the project. There was a separate day

session enumerators on details of TIPs field methodology focusing on introducing the play yards, interviewing, data quality checks, and household coding plan.

TIPs data management

Data Collection. The Trials of Improved Practices were held from 16th June to 13th July 2015. The study targeted 24

households that participated in the EE baseline study but whose babies had not reached 24 months. It was conducted in the same villages where the baseline data was collected. The villages were divided into two zones with the first zone having three villages of Mutambalika, Mpunda and Kapangula. These were the villages where traditional play shelters were constructed with the help of village members. Zone two consisted of Chiyona, Ezuleni and Chomba villages, where commercial play yards were given to caregivers.

3 visits were conducted for each participant, one week apart. Households in the community-built PY group had built a play yard within a month prior to the first visit. Households in the plastic PY group received their play yard at the time of the first visit. At the first visit, 4 trained interviewers conducted structured interviews to assess caregivers’ participation in CARE’s N@C nutrition support groups and attendance at the Baby WASH/EE education module meeting in addition to gauging caregivers’ general WASH knowledge and self-reported WASH behaviors. Interviewers also observed general hygiene characteristics of the household upon arrival.

At the second visit, an in-depth interview and a 24-hour recall of play space use was conducted. Interviewers used a semi-structured interview guide to conduct in-depth interviews.13 Based on the interview and 24-hour recall potential safety concerns were identified using a pre-formed list. The safety hazards were ranked in order of severity of outcome. Counseling was provided for the top 3 potential hazards. The participants were asked to try recommendations to minimize identified hazards for a week.

During the third visit, a 24-hour recall of play space use was conducted in addition to a review of the counseling session to determine what worked and what did not work for the caregiver, any challenges she may have faced, and recommendations for the future. Additionally, an abbreviated infant mouthing observation was conducted over 4-hours to observe the soil/stones, feces, and/or sticks that the infant

13 Based on the “Developmental Evaluation of Play Yards” interview guide developed by Zvitambo for use in the SHINE Trial in Zimbabwe


mouthed either inside or outside of the PY in the interest of exploring if the presence of the PY reduced infant mouthing episodes.

Data Entry. 2 data entrants from Cornell University travelled to Lusaka, Zambia for the summer months of data

collection for the TIPs. The data entrants conducted data entry in Microsoft Excel from the paper surveys for each round of TIPs data collected. To ensure quality of data, every questionnaire was spot checked for consistency. When deviations between two data entrants were identified the team went back to the paper questionnaire and spotted the mistakes. All the interviews were transcribed and translated from visit 2.

Data Analysis. Full verbatim transcripts were analyzed for key emerging themes using a text analysis approach.

Coding was conducted for purposes of giving quick feedback to the ongoing intervention. Researchers first read through all transcripts, took notes on key themes, questions, and concerns. Then, researchers created a list of codes with which to analyze the data. The initial set of codes about key safety concerns and motivators include:

• Researcher notes o Safety concerns o Note general quality of interview/interviewer

• Play yard use, day-to-day o How long does it take to wash the sack? o How long does it take to wash the plastic play yard? o How long does it take to sweep community built play yard? o Difficulties building the community play yard o Mentions of smeared floor in community play yard o Reasons for shifting plastic play yard o Difficulties setting up/shifting plastic play yard o # of times of use per day o # of hours child spends in play yard per use

• Family and community interactions with the play yards o What do neighbors think? o What do other family members think? o Who else gets in the play yard?

• Caregiver’s thoughts and beliefs about child in the play yard o Is the baby’s/toddler’s experience inside the play yard different than outside the play

yard? o Mentions of baby’s/toddler’s sickness o Mentions of how the baby looks o What gets placed inside play yard with baby? o Reasons for taking child out

• Caregiver’s thoughts and beliefs about play yard o Caregiver’s benefits from play yard o Issues and/or concerns with play yard o What do caregiver’s want in the future (last question) o How long do caregivers plan to use play yard? o Caregiver comments about chores:

§ How many caregivers mention chores? § What are they saying about them?


For quantitative data analysis, dummy tables were designed by Cornell initially based on the study objectives, survey questions and possible sound relationships of the variables under study. The data analysis team applied descriptive statistics to objectively present the findings of this study. Researchers analyzed the data in Microsoft Office Excel.

TIPs Challenges14 • Timing of the research. Generally the research went on well but it was conducted at the time of

harvesting and shelling of maize. The other crops of soya beans, beans and sunflower have already been harvested and sold. This is the time that is used to travel or visit relatives. It is also worth noting that harvesting and shelling is done collectively and thus this is a busy time for families in rural areas.

• It is from this background that TIPs 1-3 was conducted and 3 households dropped off. Among those who dropped off; One family household 3.2 migrated to Malawi; household 3.4 did not consent participation and household 6.3 only participated in TIPs1 but later travelled to Lusaka and we could not collect information for TIPs 2 and 3. Data was ultimately collected from 21 households from 10 traditional play shelters and 11 commercial play yards.

• The caregivers were mostly busy either with harvesting or shelling of maize and as a result were not using the play shelters a lot. Caregivers used play yards mostly they were busy with other household chores.

• May- August are winter months in Zambia and it is relatively cold according to the local standard. The cold temperatures discouraged the caretakers to put the babies in the play yards, resulting in babies using play yards only when it was warm.

• The caregivers were mostly women and it is the women’s responsibility it is to harvest the farm produce. Therefore, caregivers were busy during this time of the year. There were times when homes were visited more than twice to be able to catch the caregivers.

• There were still transport challenges because transport was shared between two program activities.

• Interviewers were new to conducting in-depth interviews, and therefore interviews appeared to be difficult to conduct. Interviewers often asked the same question over and over again without proper probing into caregivers’ answers. There also seemed to be some literacy issues reading translated interview in Tumbuka

• Some caregivers seemed confused about the questions that were being asked, cognitive testing of interview questions was not included in research protocol due to time and budget constraints. Translated and transcribed transcripts had sections that were “cut” and unavailable, either due to hearing issues or recording quality issues for the translator/transcriber.

Baseline Results Household Characteristics

We observed 30 caregiver-infant dyads for 143 hours during the household and infant observation. Field enumerators observed each infant for a median 5 hours with a range of 2 – 7 hours, depending on infant age and heavy rains. Baseline characteristics of households are shown in Table 1. All except two of the caregivers were married (93%) and 21 (70%) of the caregivers had no education or had not completed primary school. In the N@C Zambia baseline, 76% of the control and 80% of the intervention caregivers

14 From field supervisor’s notes and Cornell researcher notes


were married. “Some primary school” was the highest level of education completed by 68.9% of the control and 66.1% of intervention group caregivers, which suggests that the villages sampled in the One Health baseline are representative of the N@C study area. The mean age of caregivers was 27.7 years, which is consistent with the mean age of 28 years demonstrated in the N@C Zambia baseline. Out of 21 caregivers who reported their age,15 most caregivers (95%) were between 18 and 24.9 years old or 35 and older. The median household size was 5 people, with a median of three children per household. Most households (83%) had a dirt or cow dung floor.16

8 children aged 6 months old and under were observed as not yet locomoting or not yet moving independently. At 8 months old and above, all the infants were observed either crawling, walking, or running independently. 12 infants were crawling, 6 infants were walking on their own, and 4 infants were running on their own.

Baseline: household characteristics (n=30)

Characteristics No. (%) or median (range)

Caregiver’s age, years

≤ 18 1 (3)

18 – 24.9 12 (40)

25 – 34.9 2 (7)

≥ 35 8 (27)

Did not disclose 7 (23)

Marital Status

Married 28 (93)

Single 2 (7)

Education level of caregiver

Did not complete primary 21 (70)

Completed primary 7 (23)

Secondary 2 (7)

Total No. of HH members 5 (3 – 10)

No. children per HH

15 There is some concern that 1/3 of caregivers did not report their age due to laws prohibiting underaged marriage and the widespread practice of under-aged marriage in rural populations in Zambia.

16 Although most households (83%) had a dirt or cow dung floor, research in rural households in Zimbabwe did not find dung-smeared floors to be more contaminated with E.coli than concrete floors (Ngure, 2013).


Total 3 (1 – 8)

5 to 18 y.o. 1.5 (0 – 5)

2 to 5 y.o. 0 (0 – 1)

< 2 y.o. 1 (1 – 2)

Baseline: infant motor development milestone achievement by age

Age category 3 to < 6 mo. (n=3)

6 to < 9 (n=8)

9 to < 12 (n=8)

12 to < 18 (n=9)

18 to < 24 (n=2)

Total (n=30)

Not yet locomoting independently 3 4 - - - 7

Crawling - 4 7 2 - 13

Walking independently - - 1 4 1 6

Running independently - - - 3 1 4

Water Access

A little less than half of the households (47%, 14) had an unprotected primary water source in the form of either a stream or unprotected well. On average (median), these households have to spend about 8.5 minutes to go to their primary water sources. The self-reported time spent traveling to primary water sources ranged from 1-45 min in the households surveyed, compared to 0 – 120 minutes spent going to the primary water source as reported in the N@C baseline. In the two weeks prior to observation, six households (20%) reported that there was a whole day in which water was unavailable from the primary water source. During the most recent period of water unavailability for those six households, water was unavailable for an average (median) of 20 days, with a range of 1 – 30 days.

Baseline: primary water source

Water source No. of HH (%)

Borehole (protected) 17 11 (37)

Protected well 5 (17)

Unprotected well18 6 (20)

River/stream 8 (27)

Communal water source 29 (97)

17 This is less than the ~50% of HH from the N@C baseline census reporting that a protected borehole is the primary water source. 18 This is also less than the ~34% of HH from the N@C baseline census reporting that an unprotected well is the primary water source


Household Hygiene Characteristics 11 households (37%) owned their own latrine, a third of households shared a latrine, and 9

households (30%) did not use or have a latrine. Although 12 (57%) of the households with a latrine also had a hand-washing station near the latrine, none of those households had soap at the hand-washing station. Upon arrival, 9 households (30%) had chicken feces visible on the kitchen floor and 21 (70%) of households had spilled food or drink visible on the kitchen floor. The area where the child plays was swept in only 13 households (43%) upon arrival.

Baseline: observed household hygiene characteristics

No. (%)

Own latrine 11 (37)

Shared latrine 10 (33)

Do not use/do not have latrine19 9 (30)

Hand washing station observed 12 (57)

Water at HW station 8 (67)

Soap at hand washing station 0 (0)

Wet ground at hand washing station 7 (58)

Caregivers’ WASH practices & beliefs.

Handwashing Caregiver hand-washing with soap was uncommon, occurring on just 26 of 231 occasions of

observed hand washings, and on only 6% of 455 total hand washing opportunities. During 65 observed key fecal contact events (after adult toilet, after handling animal feces, and after diaper changes), only 40% (26) of those events precipitated caregiver hand-washing and caregivers used soap on only 8% (5) hand washing occasions.

Nine households (31%) did not have soap, and only 3 caregivers (10%) reported that they would use soap to wash hands after defecation.20 Out of the 4 caregivers who were observed washing their hands with soap after defecation, only 1 caregiver had reported they would use soap after. The other 3 caregivers observed using soap after defecation did self-report that they used soap to wash their hands. No caregiver reported using soap to wash hands after contact with animal feces, before preparing food, or before feeding a child. The top three self-reported uses for soap were washing clothes or nappies, washing cooking pots or dishes, and washing one’s body. Although 62% of caregivers reported that they washed their hands after changing a nappy, only 35% of diaper-change hand-washing opportunities observed resulted in caregiver hand-washing.

19 This is higher than the ~22-24% of HH from the N@C baseline that reported using the bush for defecation. 20 This suggests that it is really not a social norm; i.e. remarkably little “social desirability.”

kelly

Highlight


Baseline: Caregivers’ hand washing practices

Key events Opportunities No.

Any hand washing No. (%)

HWWS No. (%)

Running water No. (%)

Air drying No. (%)

After adult toilet 14 7 (50) 1 (7) 1 (7) 6 (43)

Contact with animal feces 28 11 (39) 3 (11) 5 (18) 11 (39)

After diaper change 23 8 (35) 1 (4) 0 (0) 1 (4)

Fecal Contact Subtotal: 65 26 (40) 5 (8) 6 (9) 18 (28)

After sweeping 12 3 (25) 0 (0) 2 (17) 2 (17)

Before feeding the baby 35 21 (60) 0 (0) 8 (23) 21 (60)

Before handling food 42 21 (50) 0 (0) 14 (33) 21 (50)

Before eating 26 17 (65) 0 (0) 9 (35) 17 (65)

Other 210 117 (56) 16 (8) 56 (27) 100 (48)

Key Events Total: 455 231 (51) 26 (6) 101 (22) 197 (43)

With regards to best practices of using clean, running water to wash hands, 48% (14/29) of caregivers reported using dirty dishwater to wash their hands.21 86% of caregivers reported using still water from a basin (25/29). Only 1 caregiver (3%) reported washing hands exclusively with running water from a tippy tap22. In 7 households (24%), caregivers reported using both running water from a tippy tap/water container and dirty dishwater to wash their hands. Most observed infant hand-washing events did not have a trigger activity.23 Hand washing events for infants were few, with a median of one hand washing event occurring per child during the time of observation (range 0 – 5). Of 51 observed instances of infant handwashing, only about a quarter (12 or 24%) included the use of soap. Hand washing events as part of a bath were more frequent among children between 6 to <9 months old. In children over 12 months of age, no hand-washing events as part of a bath were observed (n = 11).

Baseline: practices of washing infants' hands

Infant age category in months 3 to < 6 (n=3)

6 to < 9 (n=8)

9 to < 12 (n=8)

12 to < 18 (n = 9)

18 to < 24 (n = 2)

Total (n=30)

No. hand washing events, median (range) 1 (0–3) 2 (1–3) 1 (0–3) 1 (0–5) 2.5 (2–3) 1 (0-5)

Total no. hand washing events 4 15 11 16 5 51

No. hand washing events as part of bath 1 5 1 0 0 7

21 This suggests that these households are dealing with water scarcity at the time of the baseline survey 22 See annex for image of a latrine and tippy tap in the household. 23 This is consistent with observations of infant hand washing practices in Zimbabwe (SHINE Trial)


Hand washing with soap 2 6 1 1 2 12

Infant fecal disposal During a total of 34 observed nappy changes, infant feces were tossed in the household yard on

14 (41%) occasions. Infant feces were left unattended for >30 minutes on 7 occasions (21%).24 Feces were disposed properly in the latrine, in the garbage pit, or buried on 11 (33%) of nappy changing events.

Infant mouthing behaviors & geophagy

Caregivers’ observations and beliefs about geophagy When asked about observing their infant eating soil or feces, 28 (93%) of caregivers reported they

have seen their child eat soil. Ten of these caregivers reported that their infant had eaten soil within the past month and 7 caregivers reported that their infant eats soil regularly, defined as either every day or once per week. Five (17%) caregivers had seen their child eat chicken feces, though only one caregiver had seen their child eating chicken feces within the past month. Two (7%) of caregivers saw their child eat other animal feces, and neither caregiver saw their child eat animal feces in the past month.

When asked for free-responses about the consequences of a baby eating soil or animal feces, 40% of caregivers said that eating soil causes illness/diarrhea, 63% of caregivers said eating chicken feces causes illness/diarrhea, and 73% of caregivers said that eating animal feces causes illness/diarrhea. 60% of caregivers reported that eating soil causes stomachache, compared to 57% of caregivers who reported that eating chicken/animal feces causes stomachache. A higher rate of caregivers reported that eating soil causes worms (60%) than the response rate for chicken feces or animal feces causing worms when eaten (33% and 47%, respectively). 5 caregivers reported that eating soil was associated with closing anterior fontanel and helping baby’s guts/intestines25. Three of the caregivers who say that eating soil “helps close anterior fontanel” also believed that soil causes worms, one caregiver reported that soil eating causes constipation, and another said infants eating soil will get malaria. Only one caregiver reported that eating chicken feces would help her baby’s immunity, but that same caregiver also said that chicken feces causes a baby to have a stomachache, diarrhea, and worms, and to grow poorly.

Baseline: caregiver reports of infant eating soil

24 This is interesting because child feces carry more infectious pathogens that adult feces, and infant feces are generally considered to be less disgusting than those from older people. 25 These sentiments were also present in the formative work in focus groups among caregivers in Zimbabwe, either expressed by the caregivers themselves or expressed as advice/knowledge that elders in the community shared.

Have never seen child eat

soil 7%

Child has eaten soil in lifetime

37%

Child ate soil within

past month 33%

Child eats soil

regularly 23%

kelly

Highlight

kelly

Highlight

kelly

Highlight

kelly

Highlight

kelly

Highlight


Baseline: Caregiver reports of infant eating chicken feces

Baseline: Caregiver reports of infant eating animal feces

Baseline: self-reported caregiver beliefs about consequences of baby eating soil

Child has not eaten chicken

feces 62%

Child has eaten

chicken feces (ever) 30%

Child ate feces

within past

month 8%

Child has not eaten animal feces 93%

Child has eaten

animal feces (ever)

7%

23% 10%

60%

40%

60%

3% 13%

3% 17% 17% 17%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

% o

f Car

egiv

ers


Baseline: self-reported caregiver beliefs about consequences of baby eating animal feces

Baseline: Caregivers’ ideas to stop babies from eating soil and animal feces26

Strategy Soil, No. HH (%) Chicken Feces, No. HH (%)

Animal Feces, No. HH (%)

Placing the baby on a mat 20 (67) 16 (53) 14 (47)

Putting the baby on the back 21 (70) 21 (70) 19 (63)

Don't know 2 (7) 2 (7) 4 (13)

Other: put baby in the house 6 (20) 4 (13) 2 (7)

Other: grab out of baby's hands 3 (10) 4 (13) 1 (3)

Other: watch baby 1 (3) - -

Other: hold baby 2 (7) 2 (7) 1 (3)

Other: put baby in new area 2 (7) 2 (7) 3 (10)

Other: sweep - 1 (3) 2 (7)

Other: wash baby's hands - 2 (7) 0 (0)

Other: remove feces from area - 20 (67) 20 (67)

26 No caregiver reported that there “is nothing I can do”, rows that are highlighted include >50% of caregivers reported strategy.

30%

57% 63%

33%

3% 13% 10%

70%

27%

3%

33% 30%

73%

47%

20%

3% 3% 10%

3%

30%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

% o

f Car

egiv

ers

Baby eats chicken feces Baby eats other feces


Other: remove animal from area - 2 (7) 0 (0)

Frequency of infant mouthing episodes. Objects that were mouthed in the largest percentage of households included, in order of

decreasing % of households: the infant’s hand, food (home cooked and fresh), toys/play-things, and food utensils. Objects that had the highest mean % mouthing episodes with visible dirt were: soil/stones/feces (100%), sibling body parts (93%), sticks (88%), toys/play things (80%), and the infant’s hand (74%). The objects with the highest median number of mouthing episodes per infant included the infant’s hand (18.5 median mouthing episodes per infant), home-cooked food (16.5), the caregiver’s breast (15)27, food utensils (15), and toys/playthings (12). In addition to mouthing visibly dirty hands, play-things, siblings’ body parts, and food, 14 infants actively ingested a median of 5 handfuls of soil and stones (range of 3 – 19 handfuls) and 1 infant ingested animal feces 6 times in the span of 5 hours. Most infants mouthed objects while set on the ground, and most object mouthing occurred within the household yard and inside the house.28

Baseline: infant mouthing episodes (% with visible dirt >70% highlighted)

Object mouthed29 # of HH with mouthing episodes

with object (%)

Median number of mouthing episodes per

infant (range)

Mean % mouthing episodes with visible

dirt *Infant's hand 26 (87) 18.5 (2 – 69) 74% Breast 30 (100) 15 (7 – 53) 19% *Toys/play things 20 (67) 12 (2 – 39) 80% Food, home cooked 26 (87) 16.5 (2 – 71) 19% Food, fresh fruit 21 (70) 10 (3 – 39) 67% Food utensils 18 (60) 15 (2 – 26) 27% *Soil/stones 14 (47) 5 (3 – 19) 100% Cup 6 (20) 5.5 (2 – 8) 63% *Sibling (body part)

6 (20) 4.5 (5 – 9) 93%

*Stick 6 (20) 4.5 (3 – 9) 88% Caregiver's hand 5 (17) 4 (2 – 7) 20% *Feces, animal 1 (3) 6 (0) 100%

27 Note that in Ngure’s baby observation in Zimbabwe (2013), the caregiver’s breast was swabbed and sampled for E.coli (fecal) contamination. Minimal traces of fecal contamination were found on the caregiver’s breast, therefore breasts are not considered to be a key fecal-oral vector for infants in this rural context, though mouthing episodes of the caregiver’s breasts were still observed and quantified in this pilot study. 28 This interaction between infants and eating soil/feces can be viewed through a developmental lens. In other words, caregivers could be educated about what to look for when their infants are crawling/walking instead of thinking about it in terms of the child’s age (as IYCF is). 29 Potential fecal-oral contamination vectors


Baseline: infant mouthing locations

Location # of HH with mouthing episodes in this location (%)

Mean vector-mouth episodes in this location, excludes repeat counts (SD)

Notes

Household yard 29 (97) 15.7 (5.7) The mean vector-mouth episodes for in the yard was slightly higher (18.9) for infants aged 6 to < 9 mo (n=8)

In the house 13 (43) 5.4 (5.9) Mean v-m episodes in the house was higher (10) for infants under 6 months

Kitchen 8 (27) 3.3 (3.9) The mean vector-mouth episodes for in the kitchen was much higher (12) for infants aged 6 to < 9 mo (n=8)

Outside the yard 3 (10) 3.7 (2.9)

Animal Presence in the Household

At 3 separate time points of morning, noon, and afternoon, most animals present in the household area were free-range and only 3 households had corralled animals at any given time. This included 2 households with 6 sheep and 10 goats corralled in the morning, and 1 household with 1 caged pigeon in the afternoon. At mid-day, no corralling of animals was observed.30 The free-range animals that were most often present in the greatest percentage of household were chickens, dogs, cattle, pigs, and doves/pigeons. Chickens were most often present in the household throughout the day, with numbers ranging from 1 – 40 chickens present per household.

Large animals such as cows, pigs, and goats had the highest fecal counts in the bush, household yard, toilet, and cow/pig kraal. Small animals, such as chickens, pigeons, and doves had the highest feces count in the household yard, kitchen, bush, chicken/dove coop, and bathing area. Chicken feces were the only animal feces noted as “near infant” in the household area during observations. Additionally, 11 households had mouthing episodes on a mat (36.7%) and 28 (93.3%) households had mouthing episodes on the ground, which could indicate low mat use. The highest observable counts of feces came from chickens, pigs, and cattle; chicken feces were observed as the most prevalent form of feces, observed in 89% of households. Though 70% (28 of 30) of households had access to a latrine, human feces were found in 67% of households. Having a latrine was not associated with an absence human feces in the bush or household yard.

30 Note that many animals are brought out to the fields to graze and therefore we would expect fewer animals to be corralled at the noon and afternoon time points. For this reason, there might also be more large animals present in the household in the morning (e.g. cattle, sheep) than the noon or afternoon.


Baseline: Median number of animals not corralled in household, with top 5 animal types highlighted31

Animal Morning No. of HH (%)

Morning median32 (range)

Noon No. of HH (%)

Noon median (range)

Afternoon No. of HH (%)

Afternoon median (range)

Cattle 12 (40) 5 (1 – 26) 3 (10) 19 (1 - 30) 4 (13) 6 (1 – 26) Goats 5 (17) 5 (2 – 20) 4 (13) 4 (4 – 5) 4 (13) 7 (4 – 50)

Pigs 10 (33) 3 (1 – 16) 10 (33) 4 (1 – 16) 9 (30) 2 (1 – 16)

Dogs 16 (53) 2 (1 – 2) 13 (43) 2 (1 – 16) 15 (50) 2 (1 – 2)

Cats 2 (7) 1 (0) 3 (10) 1 (0) 1 (3) 1 (0)

Chickens 21 (70) 5 (1 – 28) 23 (77) 3 (1 – 41) 22 (73) 7 (1 – 40)

Guinea 1 (3) 5 (0) - - - -

Ducks 5 (17) 4 (2 – 5) 3 (10) 2 (2 – 6) 3 (10) 2 (1 – 2)

Doves & pigeons 6 (20) 8 (1 – 20) 7 (23) 5 (1 – 20) 8 (27) 7 (2 – 36)

Sheep 2 (7) 4 (2 – 6) - - 1 (3) 4 (0)

TIPs Visit 1 Results This section contains results from TIPS Visit 1. Tables are divided into participants with plastic play

yard (PY) and community-built play yards (PY), and in some instances compare the baseline responses to those of TIPs visit 1.

Household Characteristics

Caregiver & infant development Most primary caregivers were caregivers except for one caregiver who was the index infant’s

grandmother. Generally, number of hours/week away from child for all participants was wide-ranging from 0.5 - 9 hours/week but remained low as all caregivers spent a median of 2 hours/week away from the index child. The number of hours/week away from the child suggests that the respondent spends enough time with the child to accurately assess and respond to questions of day to day life with the index child. Respondents in the plastic PY group reported more time spent away from the child (median = 4 hours/week, ranging 1-9 hours) as opposed to the community-built PY (median = 1.65 hours/week, ranging 0.5-4 hours).

As in the baseline, gross motor development was observed for infants and toddlers. Although the 31Animals corralled at morning observation: 2 HH (6 sheep, 10 goats)

Animals corralled at noon observation: 0 HH

Animals corralled at afternoon observation: 1 HH (1 pigeon)

32 Median rounded to nearest “whole animal”


community PY group included greater numbers of older infants than the plastic PY group, the plastic PY infants were observed to have more advanced motor development. The motor development milestones were comparably distributed between the plastic PY group and the community-built PY group.

TIPs Household Characteristics (n=22)

Index child demographics Plastic PY

No. (%) (n=12) or Median (range)

Community PY

No. (%) (n=10) or Median (range)

Total

No. (%)(n=22)

Female 8 (67) 4 (40) 12 (55) Age (in months) 16 (9 -23) 15.5 (10 – 24) 15.5 (9 – 24)

Caregiver is Caregiver, biological

12 (100) 9 (90) 21(95)

Caregiver is Grandcaregiver

-- 1 (10) 1 (5)

# of hours/week away from child

4 (1 – 9) 1.65 (0.5 – 4) 2 (0.5 – 9)

TIPs: Plastic PY group motor milestone achievement

Motor development milestone 9 to < 12 mo. (n = 3)

12 to < 18 mo. (n = 5)

18 to < 24 mo. (n = 4)

Total (n=12)

Sitting 0 0 0 0

Crawling/Standing 1 2 0 3

Walking/Running 2 3 4 9 TIPs: Community-built PY group motor milestone achievement

Motor development milestone 9 to < 12 mo. (n = 1)

12 to < 18 mo. (n = 7)

18 to < 24 mo. (n = 2)

Total (n=10)

Sitting 0 1 0 1

Crawling/standing 1 2 0 3

Walking/running 0 4 2 6

Household hygiene characteristics At TIPs Visit 1, families in the plastic PY group demonstrated greater likelihood of poultry feces

visible on the kitchen floor than families in the community-built PY group. The visible poultry feces on the floor for plastic PY families and not community-built PY families could have been influenced by the building schedule of the community-built play yard, which required communities to build each household’s PY in the weeks leading up to TIPs Visit 1. In contrast, the plastic PY group received their plastic PY intervention on TIPs Visit 1, and thus has been exposed to the PY intervention for a shorter


duration of time. In contrast to the baseline observation, 0 households exhibited visible human feces around the household yard. Within the plastic play yard group, the number of household with poultry feces visible on the kitchen floor increased from 4 to 6, none of which were consistent from baseline to TIPS 1. In other words, all of the households with poultry feces visible at baseline did not have them visible at TIPS 1 and 6 new households had visible poultry feces at TIPS 1 that did not have them visible at baseline.

TIPs: Latrine ownership and access

Latrine ownership33 Plastic play yard No of HH (%)

n=12

Community-built play yard No of HH (%)

n=10

Total No of HH (%)

n=22 Own 11 (92) 7 (70) 18 (82)

Shared (Uses neighbor’s latrine) 1 (8) 2 (20) 3 (14)

Do not use 0 1 (10) 1 (5)

TIPs: Household hygiene characteristics of infant’s environment

Plastic Play yard (n=12)

Community-built Play yard (n=10)

Total (n=22)

Baseline No. (%)

TIPs 1 No. (%)

Baseline No. (%)

TIPs 1 No. (%)

Baseline No. (%)

TIPs 1 No. (%)

Poultry feces visible on kitchen floor, upon arrival

4 (36) 6 (50) 1 (9) 0 (0) 5 (22) 6 (27)

Human feces visible in household yard34

7 (64) 0 (0) 1 (9) 0 (0) 7 (32) 0 (0)

Baby WASH Behaviors & Knowledge 19/22 caregivers reported that they attended the nutrition support group that discussed the

EE/Baby WASH education modules. The caregivers who did not attend the nutrition support groups provided relatively consistent responses with caregivers who reportedly attended nutrition support groups. Almost all caregivers (21/22) reported that germs from feces inside a child can cause child to be sick/develop diseases. Participants in the plastic PY group and community-built PY group demonstrated consistency in the response “germs inside a child can cause diseases/lead child to be sick. However, participants in the plastic PY group provided more “other” responses related to alternative health conditions, such as eating feces caused malaria/cholera in infants.

100% of community play yard caregivers reported that they washed their hands after handling feces, compared to 58% of plastic PY caregivers that reported handwashing after handling feces. All caregivers from both groups reported washing hands after using the toilet. A majority of caregivers (91%) from both groups reported washing their hands before preparing or eating food. A little more than half (64%) of caregivers from both groups reported washing their hands after cleaning a child’s bottom.

33 All latrines were observed with accessible, well-trodden paths from the household 34 Note that numbers represent human feces visible at any time during baseline observation in HH yard area (median 5 hours, observed across 3 time-points morning, noon, and afternoon) and during TIPS 1 data collection (upon arrival)


83% of plastic PY caregivers and 50% of community PY caregivers reported using water from a tippy tap/water container for washing their hands and 67% of plastic PY caregivers and 30% of community PY caregivers reported using used dishwater for washing their hands. Notably, 50% of plastic PY caregivers reported using both used dishwater and water from a tippy tap for washing their hands, whereas no community PY caregivers reported using both types to wash their hands. The top uses for soap as reported by plastic PY caregivers were washing clothes/nappies (100%), washing my body (91%), Washing cooking pots or dishes (73%), and washing hands after defecation (73%). The top uses for soap as reported by community PY caregivers were washing clothes/nappies (90%), washing my body (90%), Washing cooking pots or dishes (80%), and washing hands after defecation (70%). 6 caregivers (3 plastic, 3 comm-built) reported using soap to wash a child’s hands after defecation.35

Although all caregivers responded that they could keep a clean environment for the baby by making sure the yard is swept clean of feces, additional messages such as “weeding” the yard were also reported. Half of caregivers responded that caregivers should “put all feces in the latrine,” or “Put animal feces in a deep pit far away from where young children play.” Only 4 caregivers in the plastic PY group responded that they could keep a clean environment for the baby by “putting the baby on the mat,” compared with 6 caregivers in the community-built PY group. Responses from the community-built PY group appear to be more consistent with one another than those within the plastic PY group, where participants from the plastic PY group provided more “other” responses, responses that were not anticipated given experience at the education module and baseline.

TIPs: Exposure to EE/Baby WASH education module messages36

Plastic play yard No. of HH (%)

(n=12)

Community-built play yard

No. of HH (%) (n=10)

Total No. of HH (%) (n=22)

Participated in N@C nutrition support groups 9 (75) 10 (100) 19 (86)

Exposure to education: Participated in the Baby WASH education module meeting

9 (75) 10 (100) 19 (86)

Beliefs regarding how feces are harmful to child37

Feces contain invisible germs 2 (17) 6 (60) 8 (36)

Germs inside a child can cause diseases/lead child to be sick

11 (92) 10 (100) 21 (95)

Other: Can cause stunting 4 (33) - 4 (18)

Other: Can cause diarrhea 2 (17) - 2 (9)

35 Note: HH 52 (comm-built PY) is missing data in this column 36 The way this question is phrased may have influenced caregivers’ responses; all caregivers reported at least one reason why feces is harmful to the child. Later, however, in RK7 the question asks, “How can eating feces affect a baby’s health?” At which point, three caregivers report that eating feces helps the baby’s guts/intestines. The discrepancies between responses to RK3 and RK7 are an interesting area to further explore.

37 Omitted for clarity: 1 plastic PY caregiver reported “Can be confused.”

kelly

Highlight


Other: Feces are bad things because they are wasted material, then it is careless of a caregiver

1 (8) - 1 (5)

Other: Can cause no/poor/slow brain development

3 (25) 2 (20) 5 (23)

Other: Can cause poor/weak growth38 1 (8) 1 (10) 2 (9)

Other: Causes malaria 2 (17) - 2 (9)

Other: Causes cholera 1 (8) - 1 (5)

Other: Can cause vomiting 1 (8) - 1 (5)

TIPs: Caregiver WASH Knowledge: how a caregiver can keep a clean environment for the baby39

38 Includes “Other: can cause child to grow weak” from 1 plastic PY caregiver 39 The 10 “other” responses are not considered above, see appendix for full table of responses.

100

42

58

33

25 25

100

50 50

60

20

40

0

20

40

60

80

100

Make sure the yard is swept clean

of feces

Put all feces in the latrine

Put animal feces in a deep pit far away from where young

children play

Place baby on a mat

Take feces and soil out of baby’s

hands

Wash hands after contact with feces

% o

f Car

egiv

ers

Plastic PY Community-built PY


TIPs: Caregivers' self-reported trigger events for hand washing practices

Event

Plastic PY, No. of HH (%) (n=12)

Community PY, No. of HH (%) (n=10)

Total, No. of HH (%) (n=22)

After handling feces 7 (58) 10 (100) 17 (77)

While bathing a child 3 (25) 3 (30) 6 (27)

Washing child’s hands - 2 (20) 2 (9)

After cleaning child’s bottom 8 (67) 6 (60) 14 (64)

Bathing self 1 (8) 3 (30) 4 (18)

After using toilet 11 (92) 10 (100) 21 (95)

After cleaning toilet 4 (33) 4 (40) 8 (36)

After work 5 (42) 6 (60) 11 (50)

Before feeding baby 9 (75) 8 (80) 17 (77)

Before holding/playing with baby 1 (8) 2 (20) 3 (14)

Before preparing or eating food 10 (83) 9 (90) 20 (91)

Doing dishes or washing clothes 4 (33) 2 (20) 7 (32)

Other: Just after waking up 1 (8) - 1 (5)

Other: When breastfeeding the child 1 (8) - 1 (5)

Other: After nappy wash 1 (8) - 1 (5)

Other: Wherever a person is, hands should be clean

1 (8) - 1 (5)

Other: After urinating 1 (8) - 1 (5)

Other: Before starting cleaning the plate 1 (8) - 1 (5)

kelly

Highlight

kelly

Highlight

kelly

Highlight

kelly

Highlight

kelly

Highlight


TIPs: Self-reported water sources for hand-washing

Source40




Water in tippy tap/water container 10 (83) 5 (50) 15 (68)

Used water, from dishes 8 (67) 3 (30) 11 (50)

Reported both “Water in tippy-tap/water container” and “Used water, from dishes”

6 (50) - 6 (27)

Water in basin 9 (75) 9 (90) 18 (82)

TIPs: Self-reported uses for soap




Washing clothes or nappies 12 (100) 9 (90) 21 (95)

Washing cooking pots or dishes 8 (67) 8 (80) 16 (73)

Cleaning the house - 1 (10) 1 (9)

Washing my body 11 (92) 9 (90) 20 91)

Washing my children 6 (50) 6 (60) 12 (55)

Washing my hands 6 (50) 2 (20) 8 (36)

Washing my hands after defecation 8 (67) 7 (70) 15 (68)

Washing children's hands after defecation 3 (25) 3 (33)41 6 (29)42

Washing my hands after handling animal feces 1 (8) 1 (10) 2 (9)

Washing children's hands after handling animal feces 1 (8) 1 (10) 2 (9)

Washing hands after cleaning the yard 2 (17) 2 (20) 4 (18)

Washing hands before preparing food 2 (17) 2 (20) 4 (18)

Washing hands before feeding child 1 (8) 6 (50) 7 (32)

Washing my hands before eating 1 (8) 4 (40) 5 (23)

40 One community PY caregiver reported that the water source for hand-washing included: “From the cray buckets.” This answer has been omitted from the table for clarity. 41 n=9 in this cell 42 n=21 in this cell


Washing children's hands before eating - 1 (10) 1 (5)

Attitudes about disposal of feces With regards to motivations to properly dispose of feces, every caregiver stated either “Feces is

dangerous to the child” or “When the baby is not eating feces or soil, he/she will be healthier.” Though the caregivers who reported positive health outcomes (such as helps guts/intestines) of eating soil at baseline (8/22) did not all report the same during TIPS 1, a consistent number of caregivers (7/22) reported positive health outcomes at TIPS 1.

All caregivers from both groups reported disposing of human feces in a latrine/toilet, although some households still did not have access to a latrine so this response could be more indicative of caregivers knowing what to tell the interviewer rather than a reflection of actual fecal disposal practices. 0% of plastic PY caregivers reported disposing chicken feces in the latrine/toilet, compared to 33% of the plastic PY caregivers that reported throwing other animal feces into the latrine/toilet. 42% of plastic PY caregivers reported using chicken feces and/or animal feces as manure for the garden. Only 2 plastic play yard caregivers reported sweeping chicken and/or animal feces to the sides of the yard and only 1 caregiver from this group reported throwing chicken feces into the bush. 30% of community PY caregivers reported disposing chicken feces in the latrine/toilet, compared to 60% of the community PY caregivers that reported throwing other animal feces into the latrine/toilet. Only 1 community PY caregiver reported using chicken feces and/or animal feces as manure for the garden. Only 1 community play yard caregiver reported throwing animal feces into the bush.

TIPs: Caregivers' reasons to dispose of feces (Review Knowledge #5)

Plastic PY No. of HH (%)

n=12

Community PY No. of HH (%)

n=10

Total No. of HH (%)

n=22

Feces is dangerous to a child’s health 7 (58) 8 (80) 15 (68)43

When the baby is not eating feces or soil, he/she will be healthier

6 (50) 5 (50) 11 (50)

Disposing feces in the latrine will reduce the feces in the household area44

4 (33) 7 (70) 12 (55)

When there are no feces in the area where the child plays, the child will be less likely to pick up a contaminated object and put it in his/her mouth45

7 (58) 2 (20) 9 (41)

43 Most caregivers (9/15) who answered this were those who did not give the reason below “when the baby is not eating feces or soil, he/she will be healthier.” This inconsistency could be because of phrasing, influenced by education module’s emphasis on the dangers of eating feces, and/or social perceptions of health (i.e. feces is dangerous, but not eating it doesn’t necessarily secure good health). Future research could seek to explore this inconsistency further. 44 Includes “Other: It is a habit to throw in the latrine” from 1 Plastic PY caregiver 45 Includes “Other: It can’t be easy for the child to pick feces from the latrine or pit”


TIPs: self-reported fecal disposal practices

Disposal, human feces Plastic PY, No. of HH (%) (n=12)



Throw in a latrine/toilet 12 (100) 10 (100) 22 (100)

Throw into a rubbish pit 2 (17) 1 (10) 3 (14)

Other: To the bush - 1 (10) 1 (5)

Other: Clean baby’s bottom using a cloth or heat and throw on the sides of the yard

1 (8) - 1 (5)

Disposal, chicken feces




Throw in a latrine/toilet - 3 (30) 3 (14)


Other: Used as manure in the garden 4 (33) 1 (10) 5 (23)

Other: Sweep the feces to the sides of the yard

2 (17) - 2 (9)

Other: Throw into the bush 1 (8) - 1 (5)

Disposal, animal feces (not chicken)




Throw in a latrine/toilet 4 (33) 6 (60) 10 (45)


Other: Used as manure in the garden 3 (25) 1 (10) 4 (18)

Other: Throw into the bush 1 (8) 1 (10) 2 (9)

Other: To the sides of the yard 1 - 1 (5)

Caregiver attitudes towards children eating soil/feces The most salient reported outcomes from a child eating soil or feces were “makes a baby grow poorly” and, for eating soil, “causes worms.” 82% of caregivers reported that eating soil makes a baby grow poorly and 77% of caregivers reported that eating feces causes a baby to grow poorly. More caregivers from the community PY group reported that eating feces makes a baby grow poorly (90% of community PY HH vs. 67% of plastic PY HH).

82% of caregivers responded that eating soil causes worms, compared to 27% of caregivers that said eating animal feces causes worms. 33% of plastic PY caregivers reported that eating feces causes worms, compared to 20% of community PY caregivers. Only plastic PY caregivers reported that eating soil causes malaria (33%).

41% of caregivers reported that eating soil makes a baby do poorly academically/makes the baby’s brain develop poorly compared to 64% of caregivers that reported that animal feces would make the baby’s brain develop poorly. More caregivers from the community PY group reported that eating


feces makes a baby’s brain develop poorly (90% of community PY HH vs. 33% of plastic PY HH). Soil or feces causing illness, diarrhea, and stomachache was a less salient response from caregivers. Half of the caregivers reported that eating either soil or feces causes stomachache, 50% reported that eating soil causes diarrhea/illness, and 64% reported that eating animal feces causes illness.

In the TIPs visit 1, a concerning minority of caregivers, 30% of caregivers between both

community and the plastic PY groups, reported that eating soil helps the baby’s gut/intestines. 14% of caregivers responded that eating animal feces helps the baby’s gut/intestines. Additionally, 18% of caregivers reported that eating animal feces causes malaria. Surprisingly, 30% of community PY caregivers reported that eating soil helps a baby’s gut/intestines compared to 25% of plastic PY caregivers. Other misconceptions about the effect of eating soil included the idea that eating soil helps the fontanel (17% of plastic play yard caregivers) and that soil causes anemia (25% of plastic play yard caregivers). Therefore, while the community PY caregivers might have benefited from more exposure to Baby WASH messages and the community mobilization of building the play yards, the idea that eating feces is helpful to an infant’s intestines was still present for 30% of those caregivers.

Caregiver attitudes towards infants eating soil/feces TIPs: Caregivers' perceptions of outcomes from children eating SOIL

25 17

67

33

50

33

92

17 30

0

100

50 50

70 70

0 0

20

40

60

80

100

120

Helps baby’s guts/intestines

Helps the fontanelle

Makes baby grow poorly

Makes baby’s brain to develop

poorly /do poor

academically

Causes stomachache

Causes diarrhea/illness

Causes worms Causes anemia

% o

f Car

egiv

ers



TIPs: Caregiver perceptions of outcomes from children eating animal FECES, comparison of Plastic PY group to Community PY group46

46 See appendix for full table of response

8

67

33

50

75

33 33

20

90 90

50 50

20 0

0

20

40

60

80

100

Helps baby's gut/intestines


Makes baby’s brain to develop poorly/do poor academically

Causes stomachache


Causes worms Causes malaria

% o

f Car

egiv

ers



Caregivers’ perceptions of outcomes from children eating soil, Comparing changes from Baseline to TIPS Visit 1, Plastic PY only

18

36

0 0

36

27

36

27

0

25 17

67

33

50

33

92

0

25

0

20

40

60

80

100

% o

f Car

egiv

ers (

Plas

tic P

Y o

nly)

Baseline TIPS Visit 1


Community PY: Caregivers' change in perceptions of outcomes from children eating soil (Baseline to TIPs Visit 1)

9

45

9

82

45

73

36 30

100

50 50

70 70

0 0

20

40

60

80

100

Helps baby's guts/intestines


Makes baby's brain develop

poorly/do poor academically

Causes stomachache


Causes worms Don't Know

% o

f Car

egiv

ers (

Com

mun

ity P

Y o

nly)

Baseline TIPS Visit 1


Comparison of all caregivers' perceptions of outcomes from children eating soil and animal feces

27

9

82

41

50 50

82

9 14

0

77

64

50

64

27

18

0

25

50

75

100

Helps baby’s gut/intestines

Helps the fontanelle


Makes baby’s brain develop

poorly /do poor

academically

Causes stomachache

Causes diarrhea /illness

Causes worms Causes malaria

% o

f C

areg

iver

s (Pl

astic

& C

omm

unity

PY

)

Eating soil Eating animal feces


TIPs 2 & 3 Observation Results Play Yard use and location

All 10 of the community built play yards were located in the middle of the compound. 4 of the plastic play yards (36%) were located in the household/sleeping quarters. 3 plastic play yards were in the household yard and 1 plastic play yard was in each of the following locations: outside the kitchen, middle of the compound, besides the house, on the sitting room. 1 was not out to observe. 17 (94%) of the play yards were visibly clean, while 1 (6%) was visibly dirty. The community play yards were built on an average of 5 weeks prior to the interview with a median of 4 weeks.47

100% of households used the play mat with the play yard. All (10), community play yards were visibly clean, while 5 plastic play yards (50%) were visibly clean. 13 play yards (62%) had no objects in them. 2 households (10%) had plastic toys in the play yard and 2 household (5%) had a blanket or chitenge inside. The objects were visibly clean in 16 households (84%), while 3 (16%) reported the objects being visibly dirty.

During the third TIPs visit, 100% of the community PY group caregivers had nothing in the PY at time of observation. In the third TIPs visit, 30% of HH plastic play yard households (3 HH) had nothing in the PY and the objects that were in the plastic PY ranged from plastic toys, to food, to baby shoes. Of the objects that enumerators were able to observe in the plastic PY, only 1 HH had visibly dirty objects in the PY. At TIPs visit 3, 90% of PY were observed to be visibly clean and 90% of mats were observed visibly clean. Only 1 plastic PY group play yard and mat was observed to be visibly dirty.

Of 8 households with plastic play yards, 6 (75%) were observed to have other children besides for the index child in the play yard at TIPs visit 2. 1 had a child less than 1 year (13%), 4 (50%) had children between the ages of 1-3 with a range of 0-3 children, 2 (25%) had children over 3 years old with a range of 0-2 children. 4 (80%) of the households the other children were visibly dirty, while 1 (20%) the other children were visibly clean. Of 10 households with community-built play yards, 9 (90%) – 10 (100%) reported having other children besides the index child in the play yard during the second and third TIPs visits. All 9 (90%) had children over 3 years old with a range of 0-7 children. 7 (78%) of the households the other children were visibly clean, while the other 2 (22%) did not distinguish.

Mouthing of soil and feces was reduced in the play yard. There were no observations of infants eating feces inside of the play yard, and only 1 infant mouthed soil/stones while inside the community-built play yard. 3 infants in the plastic play yard group were observed eating animal feces when they were outside of the play yard and not on the mat, though all caregivers stopped the child from mouthing the feces during observation. 4 infants in the plastic PY group and 5 infants in the community play yard group mouthed soil/stones when they were outside the play yard and without a mat. About half of the time, caregivers stopped the mouthing behavior when infants were mouthing soil and stones. 47 1 community PY caregiver did not have a response indicated, n = 9


Location of play yard and condition of play yard observed upon arrival, TIPs 2 & 3

TIPs 2 No. of HH (%)

TIPS 348 No. of HH (%)

Location of PY Plastic PY n=11

Community PY n=10

Total n=21

Plastic PY n=11

In the household/ sleeping quarters 4 (36) - 4 (19) 7 (64)

Outside kitchen 1 (9) - 1 (5) 1 (9)

Middle of the compound 1 (9) 10 (100) 11 (52) 1 (9)

Other: Inside the play yard 1 (9) - 1 (5) -

Other: besides the house 1 (9) - 1 (5) 2 (18)

Other: on the sitting room 1 (9) - 1 (5) -

Other: in the household yard 1 (9) - 1 (5) -

Other: in the yard 1 (9) - 1 (5) -

Observed condition of play yard, TIPs 2 & 3



Play yard looks Plastic PY n = 9

Community PY n=9

Total n=18

Plastic PY n = 9

Community PY n=9

Total n=18

Visibly clean 8 (89) 9 (100) 17 (94) 10 (91) 9 (90) 19 (90)

Visibly dirty 1 (11) - 1 (6) 1 (9) - 1 (5)

Unable to observe - - - - 1 (9) 1 (5)

48 Community play yard was built in place, and therefore did not move between TIPs visits


Location and condition of mat,49 TIPs 2 & 3



Location of Mat Plastic PY n=11

Community PY n=10

Total n=21

Plastic PY n=11

Community PY n=10

Total n=21

Household/sleeping quarters 4 (36) - 4 (19) 7 (64) 1 (10) 8 (38)

Outside Kitchen 2 (18) - 2 (10) 1 (9) - 1 (5)

Middle of compound - 1 (10) 1 (5) 1 (9) - 1 (5)

Other: in the play yard 2 (18) 8 (80) 10 (48) - 7 (70) 7 (33)

Other: on the chair - 1 (10) 1 (5) - 1 (10) 1 (5)

Other: besides the house 1 (9) - 1 (5) 1 (9) - 1 (5)

Other: on the sitting room 1 (9) - 1 (5) - - -

Other: In the household yard 1 (9) - 1 (5) - - -

Other: in the box - - - - 1 (10) 1 (5) Couldn’t tell because it was not out - - 1 (9) - 1 (5) 1 (9)

Condition of Mat n = 10 n = 10 n = 20 n=10 n=10 n=20

Visibly clean 5 (50) 10 (100) 15 (75) 9 (90) 10 (100) 19

(90) Visibly dirty 5 (50) - 5 (25) 1 (10) - 1 (5) Objects in play yard/on play mat, TIPs 2 & 3



Plastic PY n=950

Community PY n=10

Total n=19

Plastic PY N=10

Community PY N=10

Total N=20

Wooden toys - - - 1 (10) - 1 (5) Plastic toys 1 (11) 1 (10) 2 (11) 4 (40) - 4 (20) Blankets, chitenge 1 (11) 2 (20) 2 (11) Nothing 6 (67) 7 (70) 13 (68) 3 (30) 10 (100) 13 (65) Other: “phones” - - 1 (5) 1 (10) - 1 (5) Other: Food51 1 (11) - 1 (5) 2 (20) - 2 (10) Other: baby shoes - - 1 (5) 1 (10) - 1 (5) 49 Upon arrival at the household, all caregivers in TIPs visit 2 reported using the mat with the play yard. 50 Play mat/yard was not out in 2 HH, baby was not at home indicated at 1 HH 51 Includes snacks, “jiggies”, Sibling and plate/maize


Condition of objects n = 9 n = 10 n = 19 N = 6 N/A N/A

Visibly clean 7 (78) 9 (90) 16 (84) 5 (83) - - Visibly dirty 2 (22) 1 (10) 3 (16) 1 (17) - -

Approximate age ranges and cleanliness of other children in play yard or mat, TIPs 2 & 3

Plastic PY n=8

Community PY n=10

All (total) HH n=18

TIPs 2 TIPs 3 TIPs 2 TIPs 3 TIPs 2 TIPs 3

Age ranges of children

No. of HH (%)

Median children per HH (range)

No. of HH (%)


No. of HH (%)


No. of HH (%)


No. of HH (%)


No. of HH (%)


<1 years, 1 (13) 0 (0-1) 2

(25) 0 (0-1) - - 1 (10) 0 (0-1) 1 0 (0-1) 3

(17) 0 (0-1)

1-3 years 4 (50) 0.5 (0-3) 2

(25) 0 (0-3) - - 3 (30) 0 (0-1) 4 0 (0-3) 5

(28) 0 (0-3)

>3 years 2 (25) 0 (0-2) 3

(38) 0 (0-3) 9 (90) 2 (0-7) 10

(100) 2 (1-2) 11 2 (0-7) 13 (72) (0-3)

No other children

2 (25) - 1

(13) - 1 (10) (0-1) - - 3 -

1 (6) -

Condition of Other Children

No. of HH (%) n = 5

No. of HH (%) n = 4

No. of HH (%) n = 9

No. of HH (%) n = 10

No. of HH (%) n = 14

No. of HH (%) n = 14

Visibly clean 1 (20) 2 (50) 7 (78) 10 (100) 8 (57) 12 (86)

Visibly dirty 4 (80) 2 (50) -52 - 4 (29) 2 (14)

52 Missing response from 2 households on “visibly dirty” vs. “visibly clean” other children.


Infant Mouthing Episodes, TIPs 3

Plastic PY n=11

Community PY n=10

Object mouthed

# of HH with mouthing episodes (%)

Median mouthing episodes per infant (range)

# of HH with mouthing episodes (%)

Median mouthing episodes per infant (range)

Child is inside play yard53

Soil/stones mouthed, on mat - - 1 (10)54 0 (0-1)

Child is outside play yard55

Soil/stones mouthed, on mat - - 1 (10)56 0 (0-1)

Soil/stones mouthed, no mat 4 (36)57 0 (0-5) 5 (50)58 0.5 (0-2)

Animal Feces mouthed, no mat 3 (27) 59 0 (0-1) - -

24-‐Hour Recall Results Hour/time of day

Mothers in both the plastic and community-built play yard groups reported using the play yard during the morning and afternoon. No mothers reported using the play yard during the evening when asked during TIPS 2. In TIPs visit 3, Three households in the community-built play yard group reported using the play yard in the evening; however, households in the plastic play yard group only reported using the play yard in the morning and the afternoon. The most number of episodes and most number of households in both the community-built play yard and the plastic play yard reported using the play yard in the morning. Several mothers in both intervention arms reported using the play yard in the morning before going to the field to harvest.

53 Potential fecal-oral contamination vectors 54 Stopped child from mouthing 55 Potential fecal-oral contamination vectors 56 Stopped child from mouthing 57 There were 5 instances of a caregiver that stopped the child from mouthing, and 5 instance of a caregiver doing nothing to stop the mouthing 58 There were 4 instances of a caregiver that stopped the child from mouthing, and 2 instance of a caregiver doing nothing to stop the mouthing. On 1 occasion the caregiver didn’t see the mouthing occur. 59All caregivers stopped child from mouthing


Reason for use In TIPs visit 2, the reasons for use do not differ greatly between the plastic play yard and the

community-built play yard. The most number of episodes per household for both play yards was reported for cooking, drawing water, and doing laundry.

In TIPs 3, all households in the community-built play yard group reported using the play yard for a total of 18 episodes while cooking. However, a much lower number of households, only three, in the plastic play yard group reported using the play yard while cooking. The caregivers used the play yard most commonly for allowing the child to play, cleaning/sweeping, and sweeping. Mothers in the plastic play yard also reported using the play yard when the baby was sleeping, and when feeding the baby, though no mothers in the community-built play yard reported so. The most common reasons reported for using the community-built play yard include cooking, when going out, cleaning/sweeping, and washing plates. Mothers in the community-built play yard group also reported using the play yard when chopping firewood, washing the nappy, and bathing the child, though no mothers in the plastic play yard group reported so.

Duration of use Mothers in the community-built play yard reported overall longer duration of use of the play yard

than mothers in the plastic play yard group. However, during the TIPS 3 visit, mothers reported shorter duration of use. This change may be correlated with harvest season and increase in out-of-home responsibilities. Households in both the plastic and community-built play yard reported a wide range in the duration of use of the play yards. The duration of use reported for the plastic play yard ranged from 10 minutes to 360 minutes.

Location During TIPS 3, mothers in the plastic play yard group reported more locations where the play

yard is used, including near the washing station, in front of the chicken coop, and in the shade/under a tree. This increase in locations where the play yard is used may similarly be correlated with a change in the mother’s responsibilities from TIPS 2 to TIPS 3. The majority (9 households) of the plastic play yard group reported locating the play yard near the main house. Three households reported 6 episodes of locating the play yard in the shade or under a tree; this response reflects mothers’ concern of leaving the child in the direct sunlight without protection.

Child activity In TIPs visit 2, the most commonly reported activities among infants in the plastic play yard

group include playing with toys and playing with others, as reported by five households. Similarly, these descriptors were common among infants in the community-built play yard group; however, only two mothers reported these activities. Rather, infants in the community-built play yard group were most commonly reported as doing nothing, as reported in 7 episodes by five households.

In TIPs visit 3, the most common child activities reported for both intervention arms were playing with toys and playing with others. Mothers in the plastic play yard group additionally reported that the child was playing with food, playing, or feeding. Meanwhile, mothers in the community-built play yard reported that the child was looking at pictures, or sleeping.

Child’s mood In TIPs visit 2, caregivers in the community-built play yard reported that the infant was not happy more commonly than mothers in the plastic play yard. While no mothers in the plastic play yard group reported that the infant was not happy in the play yard, 8 households reported in 11 episodes that the infant was not happy. In TIPs visit 3, all mothers in the plastic play yard group reported at least 1 episode of the child’s mood as happy. In 1 instance, a child in the plastic play yard group was reported as not happy. This, however, differs significantly from reports from the community-play yard group. While 7 households


reported 30 episodes that the infant was happy in the play yard, 5 households reported 12 episodes that the child was not happy while in the community-built play yard.

Reason for taking child out Among households in the plastic play yard group, a wider range of reasons for taking the child

out of the play yard was reported in TIPs visit 2. These include breastfeeding, washing laundry, it getting chilly, and the child waking from a nap. The most commonly reported reasons for taking the child out of the plastic play yard include crying, breastfeeding, and when going out. Crying and when going out was similarly reported commonly among mothers in the community-built play yard group. However, the most common reason for taking the child out of the community-built play yard was after defecation.

In TIPs visit 3, crying was the most common reason reported for taking the child out of the play yard in both intervention arms as reported by 9 households in 11 episodes in the plastic play yard group and 8 households in 22 episodes by the community-built play yard group. In one episodes each, one mother in the community-built play yard reported that the child was taken out of the play yard when left alone by friends and one mother reported the child is taken out after being beaten by brother. These responses demonstrate potential changes in social interactions that the child is exposed to while being in the play yard.

Caregiver’s activity In TIPs visit 2, a wider range of activities was reported among households in the plastic play yard

group than those in the community-built play yard group. Caregiver’s activities that were common between the two groups include cooking, cleaning/sweeping, washing clothes, and washing dishes. However, only mothers in the plastic play yard group reported drawing water, pounding maize, sitting, smearing clay around the house, feeding, and fetching firewood. On the other hand, only mothers in the community-built play yard group reported bathing while the child was in the play yard.

In TIPs 3, the most common caregiver activities while the infant is in either the plastic or the community-built play yard are cleaning/sweeping, washing plates, or cooking. In the community-built play yard, caregivers additionally reported sleeping or chopping firewood while the infant was in the play yard; however, caregivers in the plastic play yard did not report these activities.

Number people in play yard with baby, and relation In TIPs visit 2, 0 adults were reported in the community-built play yard during the 24 hour recall.

However, two households in the plastic play yard reported adults in the plastic play yard with the baby. Six households in the community-built play yard group reported 10 episodes in which there were 2 other children in the play yard with the baby.

In TIPs visit 3, 0 adults were reported in the community-built intervention arm. However, two households in the plastic play yard group reported 4 adults in the play yard with the infant. A common occurrence in both play yard groups was the presence of other children in the play yard with the child. All households reported at least 1 episode of another child being in the play yard with the baby.

Age of other children in play yard In TIPs visit 2, the age of the other children in the play yard was similar between the community-

built and the plastic play yard groups. Eight households in the community-built play yard group reported 15 episodes in which the children in the play yard with the baby were between the ages of 4-6. Meanwhile, 5 households in the plastic play yard group reported 9 episodes in which the other children were between ages 4-6.

In TIPS visit 3, children in the plastic play yard group were generally reported as a younger age than those in the community-built play yard with the baby. The age of other children in the plastic play yard group was most commonly reported in the 0-3 years age range; however, the age of children in the community-built play yard group was most commonly reported in the >6 years age group.


Adult supervision In TIPs visit 2, the majority of households reported the mother as the adult supervisor of the

infant while in the play yard. In one instance each, an uncle and a grandmother were reported as adult supervisors for infants in the plastic play yard group. Similarly in 1 household with the community-built play yard, the grandmother was reported as the adult supervisor. Only 1 household in the plastic play yard group reported no adult supervision.

In TIPs visit 3, the mother was most commonly reported as the adult supervision of the child while in the play yard in both intervention arms. One household in each intervention arm reported the grandmother as the adult supervision, while one household in the plastic play yard group reported the brother. No households reported no adult supervision of the child while in the play yard.

Additional Notes In TIPs visit 2, in 2 instances the plastic play yard was not used the day of the interview because

the baby was sick (HH 65) and the baby was not home (HH 14). The household reported, “today the play yard has not been used because the mother and baby have gone to the grinding meal,” (HH 14, Recall 1). In 5 instances in the community-built play yard, the mother was reported as out. It was reported that the mother went to the garden (HH 41), the mother went to the clinic (HH 42), the play yard was used for only 2 hours in the morning then the mother went to the field until late (HH 43), the mother went to the field (HH 44), and the mother was at church the whole day before the interview and only used the play yard once the day of the interview (HH 31).

In TIPs visit 3, four mothers (HH 14, 11, 22, 61) in the plastic play yard group reported that the play yard was used only once the day before the interview as the baby went with the mother to harvest in the field. One mother in the plastic play yard group reported that the play yard was not used the previous day because the mother was sick and went to the clinic with the baby (HH 23); another mother reported that the baby went with the mother to the market, so the play yard was not used (HH 62). One mother (HH 11) reported that “the child is sick of diarrhea, feeling weak and can't sit and play on oneself in the yard and mat,” so the play yard was not used. Three mothers in the community-built play yard (HH 43, 41, and 33) reported that the play yard was not used the day prior to the interview as the mother and baby left the home to go to the clinic, stay at the maternal grandmother’s home for a holiday, and go to work at a borehole.


24-hour Recall – TIPs Visit 2

PLASTIC PY (PPY) COMMUNITY PY (CPY) Category Descriptor No. of

episodes No. of HH contributing (% of HH)

No. of episodes

No. of HH contributing (% of HH)

Time of day Morning 11 8 11 9 Afternoon 10 8 7 5

Reason for use (PPY n=10, CPY n=10)

Cooking 4 2 6 5 Drawing water 6 4 4 4 Resting 1 1 0 0 Not to eat soil 2 1 0 0 Maize-related activity 1 1 0 0

Laundry 3 2 5 4 Cleaning/sweeping 5 2 1 1 Washing/washing plates 3 1 0 0

When going to the field 1 1 1 1

Washing 0 0 2 2 Bathing 1 1 1 1 Smearing clay on floor 1 1 0 0

Fetching firewood 2 1 0 0 Duration of use60 (PPY: n=10, CPY: n =10)

< 60mins 6 6 3 3 60 to 90mins 12 9 4 4 > 90mins 4 2 11 8

Location (n=9, n=10)

Near house 12 9 - - Near the kitchen 3 3 - - In the yard 11 6 - -

Child activity (PPY: n=9, CPY: n=10)

Playing with toys 11 5 4 2 Playing with others 10 5 2 2 Playing with food 1 1 0 0 Sleeps 2 2 1 1 Playing 0 0 2 2 Looking at pictures 0 0 2 1 Nothing 0 0 7 5

Child’s mood (PPY: n=10, CPY: n=10)

Happy 21 10 7 3 Not happy 0 0 11 8

Reason for Crying 9 7 3 3

60 Duration of use for plastic play yard ranges from 5-240 minutes, duration of use for community play yard ranges from 20-160 minute


taking child out (PPY: n=9, CPY: n=10)

After defecation 0 0 7 8 Eating 2 2 0 0 Change nappy 2 1 0 0 Bathing 5 3 0 0 Breastfeeding 4 4 0 0 When going out 461 4 662 4 Washing laundry 1 1 0 0 It get chill 2 1 0 0 Child woke up from sleep 1 1 0 0

Caregiver’s activity (PPY: n=8, CPY: n=10)

Cooking 8 4 13 10 Cleaning/sweeping 2 2 1 1 Washing clothes 3 3 2 1 Drawing water 3 2 0 0 Pounding maize 1 1 0 0 Seated on the ground 2 2 0 0

Smearing clay around house 1 1 0 0

Washing dishes 3 2 4 3 Feeding 1 1 0 0 Fetching firewood 1 1 0 0 Bathing 0 0 1 1

No. of people in PY with baby (PPY: n=9, CPY: n=10)

1, adult 5 1 0 0 2, adults 1 1 0 0 1, other child 9 4 7 4 2, other children 5 4 10 6 3, other children 2 2 2 1

Age of other children in play yard (years) (PPY: n=9, CPY: n=10)

0-3 12 5 4 2 4-6 9 5 15 8 >6

4 3 4 4

Adult supervision (PPY: n=9, CPY: n=10)

Y-mother 13 7 10 10 Y- uncle 1 1 0 0 Y - grandmother 5 1 1 1 None 1 1 0 0

61 Includes “when going to the fields” and “parents were going to garden” 62 Includes “when going to the field” and “drawing water”


24-Hour Recall: TIPs 3

PLASTIC PY (PPY) COMMUNITY PY (CPY)

Category Descriptor No. of episodes


No. of episodes


Time of day (PPY: n=10, CPY: n=10)

Morning 24 10 18 10 Afternoon 8 6 14 9 Evening 0 0 5 3

Reason for use (PPY: n=10, CPY: n=10)

Cooking 4 3 18 10 When going out (drawing water) 1 1 5 5

Resting/Leisure/Just sitting 3 2 3 2 Not to eat soil/not to get dirt 3 3 0 0 Cleaning/sweeping/washing 8 4 6 4 Laundry 1 1 3 2 Playing 10 6 0 0 Washing/washing plates 3 3 4 4 Sleeping 1 1 0 0 Feeding 1 1 0 0 Chopping firewood 0 0 1 1 Washing nappy 0 0 1 1 Bathing 0 0 1 1

Duration of use63 (PPY: n=10, CPY: n=10)

< 60mins 14 7 20 8 60 to 90mins 6 5 14 9 > 90mins 10 7 8 5

Location64 (PPY: n=9, CPY: n=10)

Near main house 17 9 - - Near/behind the kitchen 5 3 - - In the shade/under a tree 6 3 - - In front of chicken coop 1 1 - - Near the play yard 1 1 - - Middle of the yard 1 1 - - Near washing station 1 1 - -

Child activity (PPY: n=10, CPY: n=10)

Playing with toys 21 8 27 7 Playing with others 8 6 5 3 Playing with food 3 3 0 0 Playing 3 3 0 0 Feeding 1 1 0 0

63 Duration of use for plastic play yard ranges from 10-360 min, duration of use for community play yard ranges not applicable. 64 “Near play yard/shelter” excluded from community-built PY tally


Looking at pictures/play yard 0 0 7 3

Sleeping 0 0 2 2 Child’s mood (PPY: n=10, CPY: n=10)

Happy 31 10 30 7 Not happy 1 1 12 5

Reason for taking child out (PPY: n=10, CPY: n=10)

Crying 11 9 22 8 Defecating/After defecation 5 4 7 6 Eating/Feeding 9 5 2 2 Take her to mother 1 1 0 0 Bathing 5 3 6 5 When going out (ex. Draw water) 2 2 2 2

To go to sleep 1 1 1 1 Left alone by friends65 0 0 1 1 After being beaten by brother 0 0 1 1

Breastfeeding 1 1 0 0 Care giver’s activity (PPY: n=8, CPY: n=10)

Cooking 4 4 16 10 Cleaning/sweeping/home chores 10 6 11 5

Wash plates/clean kitchen 7 5 8 8 Drawing water 4 4 1 1 Maize activity 3 3 1 1 Bed rest 1 1 0 0 Leisure/just seated 4 3 1 1 Eating in mother-in-law’s home 1 1 0 0

Seated/playing in play yard with child 1 1 1 1

Went to sleep 0 0 1 1 Chopping fire wood 0 0 1 1 Washing baby 1 1 2 2

No. of people in PY with baby (PPY: n=10, CPY: n=10)

4, adult 2 2 0 0 2, adults 0 0 0 0 1, other child 8 6 7 4 2, other children 8 4 10 6 >2 other children 6 2 2 1

Age of other children in play yard (years) (PPY: n=10,

0-3 17 8 5 3 4-6 14 5 13 7 >6 4 3 12 8

65 Could suggest child/children are unsupervised, also could suggest that friends were no longer playing with the index child and the index child was no longer entertained in the play yard.


CPY: n=10)

Adult supervision (PPY: n=10, CPY: n=10)

Y-mother 28 9 18 10 Y- brother 1 1 0 0 Y - grandmother 1 1 1 1 None 0 0 0 0

TIPs Interviews TOPIC PLASTIC PY (n=11)66 COMMUNITY-BUILT PY (n=10)

Researcher Notes

Safety concerns

One caregiver [HH 62] reported concern about the child's safety, as the 12-month-old child was already climbing out of the plastic play yard: "The only worry that we have is that the child climbs on the sides of the play yard, and we fear that if he falls he could hurt himself... I advise my fellow caregivers to say, when the child is playing in the play yard we should try to put in someone... to look after the child as he climbs." Another caregiver [HH 22] expressed concern about the durability of the play yard. She said, "Because when children go there they like to be hanging from the play yard so I fear maybe it can break."

Quality of Interview

There were no cuts during interviews from the plastic play yard group.

6/10 interviews from the community-built play yard group experienced cuts during the interview, discarding responses to interview questions.

Caregiver’s requests of the One Health project

Three respondents in the plastic play yard group requested for continued assistance with the play yard. One caregiver [HH 14] said, "My last thoughts are that I am very happy

7/9 (78%) of caregivers in the community-built play yard group expressed desire for toys for the child to play with while inside the play yard.

66 11 out of 12 plastic PY caregivers responded to TIPS 2 interview questions.


with this and I urge you to continue coming to advise me on this." Similarly, another caregiver [HH 11] responded, "We really want to see that this assistance can continue." However, one caregiver [HH 62] emphasized a final thought of concern for the future, "The thing is that when the child is playing in the play yard, he climbs and falls, what can we do to avoid this?"

Additionally, one caregiver [HH 44] requested the need for things to use to clean the sack, so that the sack looks neat, and things to use to clean the play yard. This same respondent reported that other caregivers feel that in using soap to wash the play yard, "we are wasting our soap because that soap is never replaced."

Researcher notes – insights, issues

One respondent [HH 11] was asked, “what makes the caregiver happy?” to which she replied, “when we wash nappies we should throw the wash water far away and when we come from using the toilet we need to wash our hands. These are the things that do not make us happy.” The caregiver’s response demonstrates the inconvenience of practices that caregivers are encouraged to exercise to protect the child’s health. Methods to improve the convenience and ease of Baby WASH practices require further research. One respondent [HH 21] stated, “What is easy is that even when you close it and keep it there even in the night you can use it.” The respondent has opened the opportunity to explore the use of the play yard at night. 3/11 caregivers in the plastic play yard group indicated the use or intended use of a reed mat beneath the sack, on which the play yard is erected.

5/9 caregivers in the community-built play yard group provided positive remarks regarding the drawings displayed inside the play yard. One caregiver [HH 33] stated, “When he is looking at the pictures that are there, they are the ones that make him happy.”

Caregivers’ play yard use Location of the play yard

Caregivers reported shifting the plastic play yard when chores are finished (1/6), to bring the play yard to the field (1/6), so that we should not vandalize it, and in response to changes in the position of the sun (3/6).

Reasons for placement of play yard revealed some feelings of community distrust. One caregiver in the community-built play yard group reported, "[The play yard was built] close to the house... Because if we can build far away others can torch it for


One caregiver noted, "It only becomes a problem when the play yard is in the sun because you need to move it into the shed but again when it is in the cold you need to put it in a warm place." Other respondents commended the fact that the play yard is easy to shift and erect. One caregiver [HH 62] reported, "It is easy because it only takes a small space; it is not large to take up space in the house." Another caregiver [HH 21] reported, "Opening and closing [the play yard] is very simple."

us but better to have it close so that we can be watching it." 71% (5/7) caregivers in the community-built play yard group reported building the play yard in an area where they could monitor/watch the child.

Washing the play yard and mat

One respondent reported never having washed the sack. However, 100% of all the caregivers who reported having washed the sack reported using soap. 2/10 caregivers reported never having washed the play yard. Whereas 100% of those who did wash the play yard, used soap.

0 respondents in the community-built play yard group reported that they never washed the play yard. The most common method of washing was using a broom to sweep the play yard several times a day.

What is difficult about the play yard?

Of caregivers that replied to this question in the plastic play yard group, over half (7/11) reported no difficulties with the play yard. Two caregivers reported that the only difficulty occurs when wanting to shift or move the play yard, e.g. when the child wants to sleep in the evening or when the caregiver wants to move to do something elsewhere. One caregiver reported that the plastic play yard is hard to close. There was no correlation observed between caregiver difficulty and age of index child.

Five caregivers in the community-built play yard group reported no difficulties with the play yard. One caregiver even reported, “it was easy because we had helped one another with our friends. There was nothing difficult.” However, five caregivers reported difficulty building the play yard. Cutting grass and trees, and roofing the structure was most commonly reported as difficult. When asked what things were done to overcome the challenges faced, one caregiver reported, “We went through a lot. The dirty was difficult to carry so that we could build.”

Reasons for using the PY: Child grows well, avoids illness

All respondents in the plastic PY group reported using the play yard to prevent the child from picking up and eating soil or animal feces, or

Over half of the community PY respondents (6/10) reported that the play yard allows the child to grow well. 8/10 caregivers in the community-built

kelly

Highlight

kelly

Highlight

kelly

Highlight

kelly

Highlight


anything outside. Over half (6/11) of respondents in the plastic PY group reported that the play yard allows the child to grow well. One caregiver [HH 11] reported the reason for using the plastic play yard “is that we want to make sure the child grows well and does not contract diseases.” Only 2/11 caregivers in the plastic PY group reported that the play yard prevents the child from becoming sick or contracting disease. While more than half of the respondents in the plastic play yard group (7/11) reported that the play yard or sack provide a clean place for the child to play, only 2/11 of the plastic play yard caregivers reported that the play yard prevents the child from becoming ill.67 Several caregivers reported that the play yard has changed the way that child looks. Particularly, one respondent [father, HH 21] in the plastic play yard group reported that neighbors like the play yard because “they have seen the change in the looks of the child.”

play yard group reported that the play yard protects the child from disease/illness or diarrhea. 80% (8/10) of community PY respondents reported that the play yard prevents the child from becoming ill. Several caregivers reported that the play yard has changed the way that child looks. In the community-built play yard group, three caregivers discussed how the play yard influences the child’s looks. One caregiver [HH 33] reported that when the child is in the play yard and sits with his friends “that is when he looks happy.” Another caregiver [HH 52] in the community-built play yard group was motivated to build the play yard because of the way the child was looking. She reported she built the play yard “because [the child] was sickly, but now he is never sickly.” Only caregivers in the community-built play yard reported influences on the child’s brain development. Two caregivers [HH 51, HH 54] in the community-built play yard group reported building the play yard so that the child can live in a better place.

Reasons for PY use: protecting infant

0 caregivers reported that the plastic play yard protects the child from fire or water.

In the community-built play yard group, 3/10 caregivers reported that the play yard protects the child from fire or water.

Play yard use and chores

Several respondents in the plastic play yard group (2/11) expressed interest in the play yard as it freed time for the caregiver to complete her chores. One respondent [HH 21], the father of the child, reported, “…once [the mother] puts the baby in the play yard, she can do a lot of chores while the child

One caregiver [HH 54] in the community-built intervention arm reported, "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 because I first have to attend to the play yard, sometime I fail to go to the

67 The high variation between the groups in this response demonstrates potential disparity in education module retention.

kelly

Highlight

kelly

Highlight


is playing…” Additionally, a caregiver [HH 14] reported, “…[the play yard] is good because I am relieved when doing chores because the child is kept busy playing.”

field." Contrary to other caregivers’ praise that the community-built play yard increased time available for chores, this caregiver believed the play yard to require too much attention, so much so that it interfered with her regular chores.

Caregiver’s thoughts and beliefs about the child in the PY Is there a difference in what your child does when inside/outside the play yard?

8/11 (73%) caregivers in the plastic play yard group reported a difference in what their child does when inside or outside the play yard. Half of those responding caregivers indicated that the child is exposed to soil/feces when outside the play yard, but is not exposed to these things when inside the play yard. One caregiver [HH 11] stated, “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.” Another caregiver stated, “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.” Two caregivers indicated that the child plays with different people if inside or outside the play yard. One respondent [HH 14] stated, “when he is inside no older children go inside because I stop them so he plays with those of his size but when he is outside the play yard he can play with anyone.” When asked who the child plays with, another respondent [HH 21] stated, “outside [the play yard] there are many others.”

4/10 (40%) caregivers in the community-built play yard group indicated that the child’s behavior is different when inside or outside of the play yard. Two caregivers stated that when the child is inside the play yard, he/she is clean and does not eat soil or feces. One caregiver [HH 53] stated, “When he is inside he is clean and does not eat soil but when he is out he eats a lot of dirt and soil.” Another caregiver remarked on differences in the child’s movement when inside versus outside of the play yard; she [HH 44] stated, “When he is the play yard he sits down to play when he is outside he moves about a lot.” This caregiver noted differences in who the child plays with when inside the play yard when she stated, “…when he is inside they stay together with his friends but when they are outside the friends go away and run away from him.” These caregivers indicate that the community-built play yard has influenced their child’s exposure to soil and feces, regular movement, and interaction with other children.

What gets placed inside the play yard with the baby? Who goes into the play yard with the

10/11 caregivers in the plastic play yard group reported that people enter the play yard with the child, 60% of which include adults, such as the caregiver or father. Children who were reported to enter the play yard

All of the caregivers (10/10) in the community-built play yard group reported that people enter the play yard with the child; in all households the caregiver enters the play yard, but in only one household, an adult other than

kelly

Highlight

kelly

Highlight


child? with the child ranged from ages 7 months to 12 years old. Just one respondent reported that no one goes into the play yard with the child. 6/8 caregivers reported that toys are placed inside the play yard with the child. These include items such as a bottle filled with corn, a phone, a ball, a toy wheel, or grain to play with. 6/8 caregivers reported that food is placed inside the play yard with the baby, as well. These includes items such as jiggies68, biscuits, yogueta sweets, groundnuts, or maheu69.

the caregiver enters the play yard, as well. The ages of the children who enter the play yard range from 20 months to 11 years old. Of the 4 caregivers asked, “what gets placed inside the play yard with the baby?” 75% reported that food is placed in the play yard. However, no caregivers (0/4) reported that toys were placed in the play yard.

Reasons to take infant out of PY

6/11 respondents reported taking the child out of the play yard when he/she cries. Five respondents reported taking the child out when leaving or going to a far place, whereas 6 respondents reported taking the child out to be bathed or change his/her clothes/nappy. Three caregivers specifically stated that the child is taken out of the play yard when he/she defecates and needs to be changed or bathed. One caregiver [HH 61] reported taking the child out of the play yard when he "needs to be changed after poo pooing or has thrown up." 4/11 respondents stated that the child is taken out of the play yard to be breastfed, while one caregiver [HH 65] stated "he plays [in the play yard] and eats food from there, but when I see that he is dirty I take him out."

Caregivers in the community-built play yard group reported fewer reasons for taking the child out of the play yard. 50% (5/10) caregivers reported taking the child out when leaving or going to a far place, such as the field or the river. However, only 2/10 caregivers reported taking the child out to be breastfed, and only 3/10 caregivers reported removing the child to be bathed or changed. One caregiver [HH 51] noted that the child is removed when he has defecated in the play yard; the child is removed "when the child has poo pooed on himself and I want to change his nappies."

Worries/issues with the play yard

Of the nine respondents asked about concerns regarding the plastic play yard, four caregivers reported no worries or concerns.

0 caregivers in the community-built play yard group expressed concern about the play yard. In fact, one caregiver [HH 33] reported, "Child is safe in play yard. Protection is there

68 Puffed corn-snacks/treats 69 sour non-alcoholic beverage made from maize or millet by lactic acid fermentation


Three caregivers (33%) reported the sun being a problem for the child while in the play yard, resulting in the need to shift the play yard.

because he is inside."

Outside Opinions

Family Members All caregivers reported positive or neutral thoughts from family members regarding the play yards, whether plastic or community-built. One caregiver from the plastic PY group [HH 52] said, “We [the family] all have one heart to see that children play in a good place.” Other children in the family also enjoy the play yard, as HH 22 noted: “They [the older children] just sit and admire the inside. Just to say we also want to sit here.”

All caregivers reported positive or neutral thoughts from family members regarding the play yards, whether plastic or community-built.

Neighbors Some caregivers reported negative and/or skeptical responses from neighbors or other caregivers. 30% (3/10) of respondents caregivers in the plastic play yard group reported that neighbors or other caregivers have disapproving or skeptical thoughts regarding the play yards. Most caregivers in both the community-built play yard group and the plastic play yard group reported positive feedback from neighbors. The tension and disapproval appears to be most prominent from other mothers in the community. HH 14 spoke of the tension with other mothers: “there are others who say these people [CARE people] are just distracting you. But I tell them that it is because they have stopped bearing children that is why they say so...[the other mothers] want to injure my feeling, because they have not seen the benefits of the play yard.” One caregiver [HH 61] in the plastic

56% (5/9) of community PY participants reported that neighbors or other caregivers have disapproving or skeptical thoughts regarding the play yards. The tension and disapproval appears to be most prominent from other mothers in the community. One caregiver [HH 41] noted that the neighbors’ negative reactions were due to jealousy, stating “others say it is good, others say it is bad but for me it is good because I use it to take care of my child… [the neighbors who think it is bad think like so] because they don’t have.” In the community-built play yard group, three caregivers reported that friends/other caregivers believe that they are wasting their time using the play yard, and that there is no benefit. One caregiver [HH 44] said, “I am still encouraging [other caregivers] to say even they say these are worthless, but you could take good care of your child in this...Problems that other caregivers are facing [is] that they feel


play yard group reported persistent community beliefs regarding positive influences of eating soil. The caregiver said, “…for me I think that it is nice that the child should be sitting in a good place, but others say eating soil makes the child immune system strong.”

is difficult about this, they say the time we take to put the child in [the play yard], we waste time that we could be doing other work, and when we are washing we are wasting our soap because that soap is never replaced. These are the difficulties that ‘kill’ them.” Another caregiver [HH 43] in the community-built play yard group reported, “Other fellow caregivers, we do advise them but the answers they give us they say, ‘you are wasting your time for nothing the benefiting is not seen, so we cannot build because we may not see the benefit.’” However, the opinions of others outside of the household did not seem to impact how the caregivers themselves thought of the play yard. One caregiver [HH 52] stated, “Those who speak bad about it we differ but those who encourage me we are together… Because I want my child to live in a better place.”

TIPs Counseling Session The 3 most common positive behaviors for the plastic play yard caregivers (n=11) were not

setting up the play yard/mat close to an open well/fire/other hazard (100%), setting up the play yard close to the household (91%), and not allowing chickens or other animals in the play yard/on the mat (91%). The top 3 most common hazards for community play yard caregivers were a dirty mat/play yard (36%), leaving food in the play yard (36%), and placing the play yard in direct sunlight (36%). Although placing the play yard in direct sunlight was commonly reported, the TIPs surveys were also conducted during the cold season of the year by Zambian standards and thus a child in the sun might be at less risk for sun exposure at this time in the year compared to other, hotter times of the year.

Enumerators also noted that one plastic play yard household had a chicken that climbed the play yard sides and another plastic play yard household had a play yard with “too many children inside.” Other concerning behaviors involved one caregiver that used the play yard without adult supervision and 2 play yards that were set up next to a fire/open well/other hazard in the household.

The 3 most common positive behaviors for the community play yard caregivers (n=10) were sweeping the play yard/mat (90%), building the play yard close to the household (90%), and not building the play yard/setting the mat next to an open well/fire/other hazard (90%). The top 2 most common hazards for the community play yard caregivers (n=10) were allowing dirty toys in the play yard (2 HH) and not enough adult supervision with the play yard (1 HH). No other hazards were documented for community-built play yard households.


Table 1. Negative behaviors documented in counseling session, TIPs 2

Negative behavior70

Plastic PY No. of HH contributing (%) n = 11

Community PY No. of HH contributing. (%) n = 10

Dirty mat/playpen 4 (36) - Dirty toys - 2 (20) Leaving food in the play yard/mat 4 (36) - Play yard/mat set up close to an open well, fire or other hazard 2 (18) -

Play yard not set up properly 1 (9) - Play yard/mat used without adult supervision 1 (9) 1 (10) Play yard/mat placed in direct sunlight 4 (36) - Other: Chicken climbing the play yard 1 (9) - Other: play yard with so many children inside 1 (9) -

Insights and Recommendations Baseline

Characteristics of the household environment In the baseline observation and survey of 30 households with infants/toddlers and free-range

livestock, we observed many free range livestock moving through the area in which the child plays and a third of households had chicken feces visible on the kitchen floor upon arrival. Chickens were the free-range animal most prevalent in the household area in the morning, noon, and afternoon observations. Caregivers reported that less livestock than usual, specifically chickens, were present in the homestead due to the seasonally dependent and bi-yearly Newcastle disease die-off. The community structure of Zambian villages presents additional challenges for a caregiver to keep the household area free of animals and feces. Houses are close together, and animals from a neighbor were observed walking through the household yard. Caregivers in this context might have less control over the presence of free-range livestock that belongs to other community members, so corralling one household’s animals would likely not reduce the risk of animal feces in that household. Additionally, sweeping is not the most efficacious way of keeping the household clean, as other studies have demonstrated that E.coli lives in the soil after feces are not visible.71

Recommendation: The community setting also presents opportunities for interventions that involve multiple caregivers and the possibility of social or caregiving support between caregivers who live very close by. Especially for older babies who are not exclusively breast fed, community play yards to share child care responsibilities could be explored.

Water sources, handwashing, and soap use Seasonality is an important physical characteristic to note with regards to WASH behaviors in this

context. Observations were conducted during the driest and hottest month of the year for Eastern Zambia, which presented issues of water scarcity for the families. Additionally, wet and dry seasons present more

70 Omitted for clarity: “Other: Putting maize inside the play yard which is… (rest of notes are illegible)” 71 Ngure, 2013


or less conducive environments for fecal bacteria to thrive.72 Just less than half of caregivers reported using unprotected water sources as their primary sources, a number of caregivers reported using dirty dishwater to wash their hands. Although soap was readily available at 62% of households, caregiver hand washing episodes with soap was not common. This finding is corroborated with prior studies across multiple country contexts of caregiver hand washing practices.73 Of the caregivers that did have soap, soap was infrequently used to wash hands and most caregivers reported using soap for washing clothes or nappies, washing her body, and washing cooking pots or dishes. Hand washing with soap after defecation or contact with feces was rare. Used water from dishes and still water from a basin was most frequently self-reported as the water source for caregiver hand washing.

Recommendation: Investigate safe water sources for households if possible and especially recommend the use of ash instead of soap for washing hands and play yards/mats.

Hand washing events for infants were few, and infant feces were often tossed in the yard or left

unattended after nappy changes. While feces were not observed in the laundry area, research in Zimbabwe found that the wet soil where dirty laundry water was dumped was contaminated with fecal bacteria indicators possibly from dirty nappies and clothes rather than visible feces.

Recommendation: Laundry areas in rural households should still be a consideration in behavior change communication due to the practice of disposing fecal contaminated water within the household yard.

Open defecation & latrine use Researchers observed human feces in the household yard and bush despite the presence of a

latrine in the households surveyed. Water, sanitation, and hygiene technology (e.g. latrines and hand washing stations) was observed at many of the households but was not connected with behavior change at the household level. Only 57% of households had a hand washing station near the latrine. And though 70% of households had access to a latrine, human feces were visible in 67% of households. Human feces were most often observed in the bush but were also observed in the household yard and, in some cases, right next to the latrine. This observation suggests that open defecation is still practiced in the households regardless of latrine access.74 Latrines were reported as relatively new, with most latrines built by the households within the past year. The CARE Zambia EE staff member noted that headmen might encourage or enforce the building of latrines by households, but perhaps do not follow up with HH to ensure the HH is using the latrine on a daily basis.75

Infant mouthing behaviors Most caregivers reported having seen their infant eating soil, and 5 caregivers reported having seen

their infant eat chicken feces. Only 2 caregivers reported having seen their infant eat other animal feces. 72 As noted in formative research in Zimbabwe, “dry hot winter days and the and the nature of sandy topsoil is a less conducive environment for survival of fecal bacteria than might be typical during the wet season.” (Ngure 2013) 73 Curtis, Valerie A., Lisa O. Danquah, and Robert V. Aunger. "Planned, motivated and habitual hygiene behaviour: an eleven country review." Health Education Research 24.4 (2009): 655-673. 74 Observers did not differentiate between child/infant feces visible and adult feces visible. Therefore, children who are too small or afraid to use a latrine might be contributing to much of the open defecation observed at the households. 75 This might also be a culturally unacceptable practice, as going to the bathroom is a private affair in these villages, and the bush offers more privacy. From CARE Zambia EE staff member: “A man could go into the bush “to collect firewood” and come back with a few sticks and maintain a sense of privacy. The latrine does not offer the sense of privacy – no one goes into the latrine to do anything other than defecate.”


The age of first soil/feces ingestion ranged between 4 and 11 months old, with a median age of 6 months. This age also corresponds with an age at which infants are frequently able to sit by themselves and are more often placed on the ground, rather than on the caregiver’s back. Although a many caregivers said that eating soil or feces causes illness/diarrhea, stomachache, and/or worms, a small but concerning minority of caregivers reported that eating soil was associated with closing the fontanel and helps the baby’s guts/intestines. There did not appear to be any clear patterns of caregivers’ understandings of the effects of infants eating soil or feces, with responses ranging from “causing ebola or malaria” to “causes the baby to lose teeth” to “closes anterior fontanel.” The caregivers who reported perceived benefits of eating soil/feces also reported a number of negative consequences of eating soil/feces, indicating either some confusion about the consequences of eating soil/feces on the part of the caregivers or indicating a more nuanced belief system of the consequences of eating soil/feces than the free-response survey was able to capture.

When caregivers were asked what they could do to prevent their infant from eating soil or feces, no caregiver reported that there “was nothing I can do.” Many caregivers reported that they could move the baby, use a mat, or put the baby on the back to prevent geophagy. These free response answers suggest that caregivers believe that they are able to stop their baby from eating soil/feces in some way. During the observation of infant mouthing activities, infants’ hands were frequently mouthed in most households and were observed as visibly dirt 74% of the time. Toys/play things were visibly dirty during 80% of mouthing occasions, and siblings were mouthed and visibly dirty on 93% of mouthing occasions. Infants were observed mouthing soil/stones, sticks, and animal feces during the time of observation.

Recommendation: Education modules were edited to educate mothers on mouthing behaviors and the danger of infants ingesting soil and feces, but since infant mouthing a sibling’s body part (hand, arm, stomach, etc.) was most often observed as visibly dirty, the social context of siblings should be considered as a major vector of fecal-oral transmission for future baby WASH considerations. This is especially important to contexts in which female children provide caregiving to their younger siblings. The polygamous household context also could present challenges for an individual caregiver’s control over the physical setting of her infant’s development.

Recommendation: Future interventions should pay close attention whether or not the caregiver is the caregiver that spends the most time with the infant. If other caregivers or group caregiving is involved, then behavior change interventions directed only at a caregiver could be less effective in interrupting the infant’s fecal-oral route.

Education Module 83% of caregivers reported attending the nutrition support group that discussed the Baby WASH

education module. Caregivers who did not attend told enumerators that there was a miscommunication about the meeting time for the nutrition support group which resulted in missing the meeting. However, the caregivers who did not attend the meeting provided fairly consistent responses with caregivers who did attend the nutrition support group meeting. The most salient reported outcomes from a child eating soil or feces were “makes a baby grow poorly” and, for eating soil, “causes worms.” “Causes worms” was a less common response for babies eating animal feces. The connection between eating animal feces/soil and poor brain development was a less powerful connection than growing poorly. Only about half of caregivers reported that eating soil/feces makes a baby do poorly academically/makes the baby’s brain develop poorly. The idea that soil or feces causes illness, diarrhea, and stomachache was a less salient response from caregivers. Even after the education module delivery, a small but concerning minority of caregivers reported that eating soil helps the baby’s gut/intestines. Additionally, 18% of caregivers reported that eating animal feces causes malaria.

Recommendation: Clearer communication about nutrition support group meeting times and information is needed to reach all targeted women with infants and toddlers.

Recommendation: Education modules should encourage women to share knowledge with their families and with their communities and encourage women to support one another in keeping infants from


eating animal feces in this community context. Encourage women to share barriers/facilitators to implementing Baby WASH suggestions in group settings.

Recommendation: Explore deeply held beliefs of soil eating – why do women feel it helps the baby’s guts/intestines? Where did they learn about this? Who in the community believes that eating soil can be positive? Address the response that soil/feces eating can help a baby’s gut/intestines – find out where that is coming from and address it in a more meaningful way than the education module does currently.

Recommendation: Emphasize the negative effects that geophagy (eating soil/feces) has on infant growth – infant physical growth was reported most by caregivers for both soil/feces eating. Additionally, it seems that the education around the connection between soil and worms is a strong one to continue to emphasize – additional emphasis should be on the connection between animal feces and worms.

Recommendation: Malaria prevention came up multiple times in caregivers’ responses to keep a clean environment for their baby. Combining the concepts of malaria and physical growth/Baby WASH could be an effective way of emphasizing a clean environment for baby as a concrete set of actions.

Trials of Improved Practices

Mouthing Behaviors and Babies’ Experiences with Play Yards Babies were not mouthing soil while in the play yards but started mouthing items while outside the

play yard. In most instances, caregivers were stopping the babies from mouthing dirty items while researchers were observing. Keeping a clean environment for the baby to help the baby grow and to reduce illness was a salient belief among caregivers and their immediate family. A few caregivers noted that the play yard was beneficial as it keeps the baby cleaner for longer. Even after education modules, caregivers noted that they believe eating soil is good for the baby’s guts/intestines, and a few caregivers mentioned that neighbors also believe that geophagy is good for the baby’s guts/intestines.

Recommendation: These deeply held beliefs will need further study and community outreach to both understand the underpinnings of the perceived benefits of eating soil and change communities’ perceptions of babies eating soil.

Mouthing of soil and feces was reduced in the play yard. There were no observations of infants

eating feces inside of the play yard, and only 1 infant mouthed soil/stones while inside the community-built play yard. 3 infants in the plastic play yard group were observed eating animal feces when they were outside of the play yard and not on the mat, though all caregivers stopped the child from mouthing the feces during observation. 4 infants in the plastic PY group and 5 infants in the community play yard group mouthed soil/stones when they were outside the play yard and without a mat. About half of the time, caregivers stopped the mouthing behavior when infants were mouthing soil and stones. It is not clear if mothers stopped children from eating soil because enumerators were observing or if this was a natural behavior.

Recommendation: Continue to encourage caregivers to watch infants when outside of the play yard for mouthing behaviors. Allowing children to eat soil/stones when outside of the play yard could also be related to deeply held beliefs about the benefits of children eating soil.

Caregivers indicated that the community-built play yard has influenced their child’s exposure to soil

and feces, regular movement, and interaction with other children. Households in both the plastic and community-built play yard reported a wide range in the duration of use of the play yards. The duration of use reported for the plastic play yard ranged from 10 minutes to 360 minutes. A greater portion of mothers in the plastic play yard group indicated that there is a difference in what the child does when inside versus outside the play yard. Respondents in both play yard groups indicated that the child’s exposure to soil or feces differ, in addition to the child’s interaction with other people. In the community-built play yard group, only, a mother indicated that the child moves less when in the play yard than when outside.


Entertaining babies while in either play yard was identified as a challenge by caregivers. Babies enjoyed being in the play yard as long as other children or siblings were there. Only a few households had given some sort of toy to the baby, making it difficult to play alone. A few caregivers noted that the baby plays with many more children outside of the play yard and plays with much fewer children when inside the play yard. Siblings are often supervising and interacting with crawling and toddling infants, and thus interaction between infants and siblings in this context should be explored further.

Recommendation: Future education interventions could include siblings of young children and encourage siblings to also keep their baby brother/sister from eating soil/feces. Introduction of play yards could also include a short introduction to ideas for toys in the play yards. Local materials such as cleaned plastic containers and dried corncobs (large enough so the baby cannot swallow/choke on) can be used inside the play yard for entertaining the baby. Some caregivers have reported using local materials for toys, so soliciting other caregivers’ thoughts on making toys for their child could help babies stay entertained in the play yard.

Caregiver’s Experience with the Play Yards and Baby WASH Even though a number of caregivers still reported believing that eating soil helps a baby’s

guts/intestines, the WASH practices had greatly improved in most of the households. The yards were swept upon arrival and most households had managed to build latrines with hand washing facilities. Notably, poultry feces were still visible in 50% of plastic play yard households’ kitchens and in only 1 community PY household’s kitchen upon arrival for TIPs visit 1. Human feces was not observed.

Mothers used play yards mostly they were busy with other household chores. Although a few caregivers shared that the play yard allows them to more easily do their chores, the Baby WASH intervention still adds more activities to a caregiver’s day, and more exploration is needed to determine if the play yard intervention saves a caregiver time. Seasonality, both during harvest seasons and dry seasons, appears to play a large role in the ability of caregivers to practice Baby WASH. For example, during the dry season water scarcity was an issue and during harvest season, caregivers typically only used the play yard once a day in the morning before going out to the fields for the rest of the day.

Recommendation: Explore the seasonal effectiveness and acceptability of Baby WASH interventions. Is the community play yard acceptable in all seasons? What chores interfere with Baby WASH practices, and what chores do the play yard/Baby WASH practices make easier? (e.g. using the play yard once in the morning before going out to the fields is acceptable) Tailor education modules to caregivers’ and communities’ experiences of seasonal change and assess caregivers’ acceptability of associated Baby WASH chores.

A number of caregivers, when asked about keeping a clean environment for their infant, mentioned

strategies associated with reducing the risk of malaria and breeding mosquitos in the household. Recommendation: Future education modules can incorporate both malaria messages and Baby

WASH messages to present a more cohesive strategy to keep a clean environment for a growing baby. Additionally, integrating fecal disposal messages into gardening educational modules can further strengthen the practice of taking feces out of the household yard and using animal feces as manure in the garden.

As expected, baby hand washing was still a challenge for most caretakers. Additionally, a few

caregivers mentioned difficulty in building/setting up the play yard, reported taking much more time to wash the mat and play yard, and expressed difficulty in using so much soap when it is not easy to replace. Even during the winter and out of the dry season, caregivers still reported using dirty dishwater to wash their hands. One caregiver also expressed dissatisfaction about washing her hands after using the toilet and disposing of dirty laundry water at the far edge of the household yard.

Recommendation: Future education modules on gardening could position dirty laundry/dish water as good water to use on the household garden rather than using it for hand washing or letting that water go to


waste, if deemed appropriate by CARE intervention staff. In any case, water scarcity and access is a key issue in these communities if they are to practice the most effective WASH practices.

Safety concerns The top 3 most common hazards for community play yard caregivers were a dirty mat/play yard

(36%), leaving food in the play yard (36%), and placing the play yard in direct sunlight (36%). Although placing the play yard in direct sunlight was commonly reported, the TIPs surveys were also conducted during the cold season of the year by Zambian standards and thus a child in the sun might be at less risk for sun exposure at this time in the year compared to other, hotter times of the year.

Enumerators also noted that one plastic play yard household had a chicken that climbed the play yard sides and another plastic play yard household had a play yard with “too many children inside.” Other concerning behaviors involved one caregiver that used the play yard without adult supervision and 2 play yards that were set up next to a fire/open well/other hazard in the household. In the interviews, a few caregivers mentioned concerns about children climbing out of the play yard and a 12-month-old child was already climbing out of the plastic play yard at the time of TIPs visit 2.

The top 2 most common hazards for the community play yard caregivers (n=10) were allowing dirty toys in the play yard (2 HH) and not enough adult supervision with the play yard (1 HH). No other hazards were documented for community-built play yard households. From Recommendation: Children who climb will be able to climb out of the plastic play yard. Therefore, the plastic play yard is not recommended for children who climb. Additionally, the plastic play yard had more documented hazards in counseling sessions than the community built play yard overall. With appropriate adult supervision and cleaning, the community play yard is recommended for further study and use.

Community Reactions

There was a lot of cooperation with health center staff and traditional leadership throughout the research process and during the building phase the community members seem to have accepted the traditional play shelters (evidenced by two families outside of the selected participant households who pleaded with community members to have play shelters built for them). Neighbors’ reactions to the play yards ranged from supportive to mocking to critical. Most caregivers in both the community-built play yard group and the plastic play yard group reported positive feedback from neighbors. The tension and disapproval appears to be most prominent from other caregivers in the community. During interviews participating caregivers mentioned negative opinions, judgment, and mockery about the play yards from other neighbors and other caregivers. Negative opinions from outside of the family included neighbors thinking that the play yard/mat is a waste of both time and soap, neighbors not seeing the benefits of the play yard/mat, and neighbors wondering how the child will grow if the child is in the play yard. Some of the participating caregivers noted that these negative opinions are due to jealousy, and caregivers reported not being affected by the negative opinions of neighbors. Family reactions to the play yards seemed to be generally positive/accepting.

Recommendation: More community-level sensitization is necessary to understand the neighbors’ negative reactions to the play yards that caregivers reported in interviews.

Concluding Notes

While the CARE-Cornell One Health project was delayed in the beginning, it was delayed within the context of the Zambian Nutrition at the Center project, and thus still has the potential to be integrated into the educational activities of CARE Zambia’s N@C interventions. One key success has been the relationship building and communication throughout the CARE-Cornell collaboration through face-to-face visits, regular phone/skype calls, and regular email communication. This relationship has developed into a stronger relationship between the One Health team, Dr. Stoltzfus’s research group, the Cornell


Global Health program, SAIPAR, CARE Zambia, and CARE USA. Additionally, CARE is committed to incorporating One Health insights into an integrated water, sanitation, and hygiene program for communities in Lundazi and Chadiza. The One Health project has both explored the context of geophagy in rural Zambia and developed a low-cost and more sustainable intervention model for Baby WASH than was previously available. This was done through the creation of contextual education modules and the design of a community-built play yard to separate infants from feces in their home environments. Our successes and insights have included:

1. The creation of a context-specific education module and materials for communities to learn about Baby WASH and the risks of infants eating soil/feces.

2. A comparison of two types of Baby WASH play yard interventions: a plastic, imported play yard and a community-built play yard with traditional building materials and methods.

3. The adaptation of methods to explore infant geophagy in future locations. 4. Highlighting key questions and future issues to explore around infant geophagy and Baby WASH

interventions in rural contexts. For future work, the hand washing and open defecation observations emphasize both the

importance of effective behavior change education and understanding caregiver priorities when introducing baby WASH technologies. Exploring sustainable solutions that address multiple facets of WASH is crucial in communities where water is untreated or unavailable and latrine utilization is checkered. Studying the household context of infant mouthing behaviors should guide future interventions on improving domestic hygiene with country-specific practices and guidelines. A clear separation of the infant from the frequently contaminated soil while supporting a young child’s development with a community-built play yard appears the most practical and feasible way to reduce the risk of exposure to fecal bacteria from these environmental sources. A physical and “visual marker” of a “clean space” for babies could help caregivers reduce the workload needed to keep the entire yard/household clean. Educating communities on personal and environmental hygiene and safe disposal of human and animal feces should complement efforts to provide a clean environment for young children to promote community built solutions, offer support to caregivers, and decrease negative community reactions.

On a larger scale, the One Health project builds upon the growing Baby WASH agenda, building collaborative understandings and relationships, building a local play yard with the support of the community, and integrating Nutrition @ the Center initiatives with One Health insights, both on the CARE USA international level and the CARE Zambia country level. Completion of the project report for CARE is a major milestone that moves the project into a completed stage and allows for CARE to disseminate and scale up our findings in One Health to the CARE Zambia intervention district and the rest of the N@C country offices.


Appendix

Table 18. TIPs 1: Caregiver ideas on how to keep a clean environment for child

“How a caregiver can keep a clean environment for the baby?”

Plastic play yard, No. of HH (%)

(n=12)

Community-built play yard, No. of HH (%) (n=10)

Total No. of HH (%) (n=22)

Make sure the yard is swept clean of feces 12 (100) 10 (100) 22 (100)

Put all feces in the latrine 5 (42) 5 (50) 10 (45)

Put animal feces in a deep pit far away from where young children play

7 (58) 5 (50) 12 (55)

Place baby on a mat 4 (33) 6 (60) 10 (45)

Take feces and soil out of baby’s hands 3 (25) 2 (20) 5 (23)

Wash hands after contact with feces 3 (25) 4 (40) 7 (32)

Other: Put the child on the back 1 (8) - 1 (5)

Other: Wash hands before feeding76 1 (8) - 1 (5)

Other: Sprinkling of water on the yard, domestic animals must stay away from people*

1 (8) - 1 (5)

Other: Using boiled drinking water 1 (8) - 1 (5)

Other: Clear/weed the yard 2 (17) - 1 (5)

Other: Change the baby’s clothes when baby is dirty

- 1 (10) 1 (5)

Other: Clean food and the caregiver should be clean, as well.

- 1 (10) 1 (5)

Other: Baby should be placed in a clean play shelter77

1 (8) 1 (10) 2 (9)

Other: Remove (chase) animals away from the play yard

1 (8) - 1 (5)

Other: Where the baby is playing must be swept - 1 (10) 1 (5)

Other: Remove feces from the yard 1 (8)

76 Unclear if the caregiver is referring to the child’s hands or her own hands 77 Includes “Putting the baby in play house”


Table 20. TIPs: Caregiver perceptions of outcomes from children eating SOIL

Plastic PY No. (%)(n=12)

Community PY No. (%)(n=10)

Total No. (%)(n=22)

Self-reported beliefs Baseline TIPS 1 Baseline TIPS 1 Total, TIPS 1

Helps baby's gut/intestines 2 (18) 3 (25) 1 (9) 3 (30) 6 (27)

Helps the fontanel 4 (36) 2 (17) - - 2 (9)

Makes baby grow poorly - 8 (67) 5 (45) 10 (100)

18 (82)

Makes baby’s brain develop poorly/ do poor academically

- 4 (33) 1 (9) 5 (50) 9 (41)

Causes stomachache 4 (36) 6 (50) 9 (82) 5 (50) 11 (50)

Causes diarrhea/illness 3 (27) 4 (33) 5 (45) 7 (70) 11 (50)

Causes worms 4 (36) 11 (92) 8 (73) 7 (70) 18 (82)

Causes malaria - 2 (17) - - 2 (9)

Don’t Know - - 4 (36) - -

Other: Painful during defecation due to very thick feces

1 (9) - - - -

Other: Causes difficulties in defecation 2 (18) - - - -

Other: Can cause stunting - 1 (8) - - 1 (5)

Other: Can cause shortage of blood - 1 (8) - - 1 (5)

Other: Can cause anemia - 2 (17) - - 2 (9)

Other: Can cause pneumonia - 1 (8) - - 1 (5)

Other: Can cause poor bone development - 1 (8) - - 1 (5)

Other: Can constrict the intestines - 1 (8) - - 1 (5)


Table 21. TIPs: Caregivers' perceptions of outcomes from children eating animal FECES

Plastic PY No. (%)(n=12)

Community PY No. (%)(n=10)

Total No. (%)(n=22)

Beliefs Baseline TIPS 1 Baseline TIPS 1 TIPS 1

Helps baby's immunity - - 1 (9) - -

Helps baby's gut/intestines - 1 (8) - 2 (20) 3 (14)

Helps the fontanel - - - - -

Makes baby grow poorly - 8 (67) 7 (64) 9 (90) 17 (77)

Makes baby’s brain develop poorly/ do poor academically

1 (9) 5 (42) - 9 (90) 14 (64)

Causes stomachache 5 (45) 6 (50) 9 (82) 5 (50) 11 (50)

Causes diarrhea/illness 8 (73) 9 (75) 10 (91) 5 (50) 14 (64)

Causes worms 1 (9) 4 (33) 9 (82) 2 (20) 6 (27)

Causes malaria 5 (45) 4 (33) - 1- 4 (18)

Causes baby to lose teeth - - 2 (18) - -

Don’t Know 3 (27) - 6 (55) - -

Other: Can cause cholera - 1 (8) - - 1 (5)

Other: Can cause stunting - 1 (8) - - 1 (5)

Other: Can cause vomiting 2 (18) 1 (8) - - 1 (5)

Other: Can cause sores in the stomach - 1 (8) - - 1 (5)

Other: Causes cough 2 (18) - - - -

Other: Can cause ebola 1 (9) - - - -


1.1. Nutrition at the Center, Results Framework


Context in Images

Example of village in rural Eastern Province, Zambia – concentrated households of many families presents a challenge for mothers, as neighbors’ animals freely roam and defecate.

Example of village in rural Midlands, Zimbabwe – dispersed homesteads households of fewer families. Example homestead circled in orange.

Example of rural latrine and “tippy tap” handwashing station without a worn path to either from the household


Community-‐designed play yard mock-‐up, based off of traditional Zambian kitchen and meeting space structures.

Community-‐designed play yard, detail showing paintings of fruit, cups, flowers, and shapes on the inside of the play yard.


Young children in the community-‐designed play yard, sitting on top of locally-‐crafted mats

Community group in front of the play yard they designed and built, with original sketch on the right.

Documents

0. One Health Report for CARE Version 7 · risks of fecal exposure to children’s health and development. Education Modules. Education modules were modified from Zvitambo’s education