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Undernourished children in low-income contexts often suffer from environmental enteric disorder—damage to the intestines probably caused by chronic exposure to bacterial pathogens from feces. We aimed to identify strategies for reducing infants and young children’s (IYC) exposure to human and animal feces in rural farming families by conducting direct observation of 30 caregiver–infant dyads for 143 hours and recording water, sanitation, and hygiene (WASH)–related behaviors to identify possible pathways of fecal–oral transmission of bacteria among IYC in rural Zambia. In addition to mouthing visibly dirty hands, toys, sibling’s body parts, and food, 14 IYC actively ingested 6.1 ± 2.5 (mean ± standard deviation [SD]) pieces of soil and stones and one ingested animal feces 6.0 ± 0 times in the span of 5 hours. Ninety-three percent (21 of 30) of mothers reported observing the index-child eating soil and 17% (5 of 30) of mothers reported observing the index-child eating chicken feces. Adult and child handwashing was uncommon, and even though 70% (28 of 30) of households had access to a latrine, human feces were found in 67% of homestead yards. Most animals present in the household were un-corralled, and the highest observable counts of feces came from chickens, pigs, and cattle. To protect IYC in low-income communities from the exploratory ingestion of feces and soil, Baby WASH interventions will need to interrupt fecal–oral microbial transmission vectors specific to IYC with a focus on feasibility, caregiver practices, and local perceptions of risk.
The study was conducted in collaboration with CARE USA’s Nutrition at the Center (N@C) program in rural Zambia. N@C is a 5-year intervention designed to improve nutritional outcomes for mothers and children (age 0–24 months) through interventions in maternal, infant, and young child nutrition and health, WASH, food security, and women’s empowerment. The study took place in six rural villages participating in the N@C program in the Lundazi District of Zambia, close to the Malawi border. The main tribes in the Lundazi District are Tumbuka, Chewa, and Ngoni. The language most commonly spoken is Tumbuka, which is the main language of only 2.5% of Zambia’s population.23,24 The Tumbuka are 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.25 The district town of 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.23 In general, villages consist of one area with multiple homesteads and support structures and a secondary area of fields with crops. Thirty households from six villages with IYC between 3 and 24 months old were purposively selected from four health center catchment areas. 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 (Figure 1). Typical household structure layout, Eastern Province, Zambia. This figure appears in color at www.ajtmh.org. Following the methods of Ngure et al.,15 we observed infant and caregiver behavior with a semistructured data collection tool to record mouthing episodes, caregivers’ handwashing behaviors, washing of infant’s hands, and WASH technologies. Observation visits were conducted on any day of the week, excluding Sunday. Researchers observed all objects that were mouthed by the target-child, whether the object was visibly dirty, and the frequency of object-mouth episodes. Mouthing was defined as putting any item or fingers in to a target-child’s mouth, regardless of ingestion. Repeat mouthing episodes of the same object were also observed. Researchers observed and recorded the mother’s handwashing behavior during handwashing opportunities, defined as after adult toilet use, contact with animal feces, after diaper changes, after sweeping, in preparation to feed the infant, in preparation to handle food, and in preparation to eat. Researchers observed and recorded any infant diaper change and the first five infant handwashing episodes observed were recorded along with triggering events (e.g., infant crawling on dirt, before feeding episodes, after diaper changes, etc.). The second researcher also used a pretested, structured observation tool to conduct spot checks on the cleanliness of the caregivers’ and IYC’s hands and determined whether the household had a handwashing station and functional latrine, and whether there was evidence of their recent use. A qualitative questionnaire was used to conduct interviews with the mother regarding water, hygiene, and sanitation practices in addition to beliefs about IYC ingestion of soil. The questionnaire followed the standard caregiver questionnaire modules for water access, hygiene and sanitation access and behaviors, household characteristics, and demographics in the sanitation hygiene infant nutrition efficacy (SHINE) trial with additional measures of infant development structured around the Multiple Indicator Cluster survey’s questionnaire for children under five.26,27 We created a research tool to quantify the free-range livestock present in the household. At three time points—in the morning upon arrival, at noon, and in the afternoon at the end of the observation session—researchers conducted spot checks and recorded the number of corralled and roaming animals and the location and type of animal or human feces throughout the household and yard. On the first visit to each household, research staff introduced the study and obtained oral informed consent to participate in the study from the index-child’s caregiver. All respondent caregivers were the index-child’s mother. The informed consent was read to the mother in Tumbuka. The Tumbuka version of the consent form was translated and back-translated by the field research staff under the supervision of the field supervisor before the study. The Institutional Review Board of Cornell University (Ref. No. 1405004690) and the University of Zambia Biomedical Research Ethics Committee (Ref. No. 013-11-13) approved this study. Research visits were conducted between 7:30 am and 3:00 pm in each of the 30 households on all days of the week except Sunday. In the morning, researchers first observed the relative cleanliness and characteristics of the household. One researcher was tasked to follow the index-child and record episodes of mouthing behaviors. A second researcher observed WASH behaviors of the primary caregiver and conducted spot checks and recorded the number of corralled and roaming animals at three time points throughout the observation and interview process. This researcher also counted the number and location of animal and human feces present in the household at the same three time points. In the afternoon, after completing the infant observation, the researchers used a pretested, structured questionnaire to record mothers’ self-reported household demographic information, hygiene practices, water access, and livestock ownership. Researchers also asked open-ended questions on caregivers’ beliefs about IYC eating soil and animal feces. To maintain the quality of data, the field supervisor conducted random spot checks with each research staff pair throughout the observation process and the researchers conducted debriefing sessions at the end of each day after household visits. Researchers double-checked and cross-checked questionnaires and the recording of key events and behaviors to maintain consistency in data collection. After all infant observations, data were analyzed to identify the key potential vectors, defined as 1) objects mouthed most frequently and 2) objects that were ever mouthed and were most visibly dirty.14
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