Background
REDUCE program
Care Group model
Study objectives
Project overview
Component I: Exploratory research
Methods
Results
Child mouthing behaviors
Caregivers said that most children play in the yard on the bare earth, and that very young children put “whatever they find” in their mouths, including soil, dirty objects, and feces because they “do not know any better.” Caregivers described a connection between mouthing or eating dirt or dirty things and nyoka mtumbu, or ‘snakes in the belly,’ a local term for intestinal worms.“I leave [the baby] with his four-year-old brother. I leave them and I say ‘I'm leaving you here and I'll come back. Rest and play until the others get back from school.’" –Mother
When asked what kinds of games children regularly play, participants said children pretend to make “fufu” (a local staple food made of corn or cassava) using mud, and that while older children know better than to eat “mud fufu,” they may feed it to younger siblings, who swallow it.“Sometimes a child can get sick and you leave him at home because you lack the money to treat him… They're not going to give you medicine for nothing. And if you treat him today, tomorrow you can't [get treatment] because you won’t have money.”–Mother
Several participants suggested a carpet or a mat to prevent children from touching or playing with dirty things.“[Feces is] poison – that's what our parents used to say. A person can't eat feces, and if he eats it, he won’t go on living because it contains a lot of microbes.”–Community leader
Limited financial resources were reported as playing a major role in household decision-making and ability to purchase or construct clean and engaging spaces for children to play. When we asked about playmats as a possible intervention, some said a child might be happier to stay on a playmat if they were given toys to occupy them, but also noted that toys could be expensive.“You see here, outside, there is the ground, and if there was a clean place ... he wouldn't eat dirt. If we had a tarp, we could sit the child on the ground, and he wouldn't eat dirt anymore.”–Community leader
Participants commented that children might not like a playmat if they were left alone on it but suggested that if other family members kept the child company, they would accept being placed on the playmat.“If we were in a place with means, if we could buy the child a toy … that would help him not to touch everything.”–Community health worker
“If a parent is present or other children with whom he plays, the child will not be afraid [of the playmat]”–Mother
Child feces disposal
Participants noted that there might be some delay in disposal of child feces if parents were working away from the home, especially if the person looking after the child in their absence was preoccupied with other activities.“We had a small toilet for children but people told us never to use these toilets again because they are a source of flies that bring germs everywhere in the neighborhood.” –Mother
When children defecated in diapers, participants said they washed the diaper and the child upon noticing the child needed to be changed. Most reported disposing of feces in the latrine; however, some reported disposing of some diaper wash water in the yard or field.“The feces of a small child who has already started to eat has many microbes, and an infant who has not yet started to eat all sorts of food does not have too many microbes.” –Mother
“I throw [the feces] in [the toilet] after I return. I wash his clothes and spread them out… I throw the first wash water (used for washing diapers) in the hole (latrine) and the second wash water I throw in the yard.” –Grandmother
Living and interacting with animals
Animals were seen as an important source of income and food. Many families kept small animals, such as rabbits and guinea pigs, in their kitchen areas, and some families kept larger animals, such as cows and pigs, in their kitchens and homes at night to prevent them from being stolen.“We've lived together with animals for a long time, that's how we raise them here. We're already used to [living with animals] and it doesn't cause a problem.” –Community leader
Some participants said that they would prefer to keep their animals in a separate home or structure; however, many among this group noted that it was beyond the means of many families to construct a separate space for animals. Commenting on the practice of sharing a home with animals, a few participants felt animals should not sleep in the same place as people.“It's also to avoid theft. When you have two or three houses, you will put the animals you're raising in one house and you will stay in another. Two or three days later, people will realize that nobody is sleeping in the house with the animals, and then thieves will visit you and steal [them]. Like me – yesterday I had a chicken stolen from the house because they knew no one was spending the night [in the same room as the chicken].” –Community leader
Some respondents also expressed concerns that animals living in close proximity with humans might cause the animals to be hurt by children playing.“An animal can’t spend the night in the same place as a person. He must have his own house …but sharing the house with the animal? No, because the animal has a lot of illnesses.”–Father
When participants were asked if they would be open to sweeping up animal feces and throwing it in the latrine, participants voiced very strong opposition and argued for its utility in agriculture.“After touching [cow] dung we always say, ‘It's not dirty,’ because it has come freshly from the stomach of a cow where there is no dirt.”–Father
Participants frequently mentioned that small animals, such as rabbits and guinea pigs, could not be kept outdoors because if small animals were allowed to get cold, they would die.“Animals’ excrement is important to us because we use it as fertilizer.”–Father
“The kitchen is the best place [for rabbits and guinea pigs] … if we put them [outside, it] is very cold and they will die. I once kept guinea pigs [outdoors] and they died – and I even put the rabbits [outside], and they died too, and people began to advise [me] not to keep animals where there is no fire, so I tried putting them in the kitchen and they did not die anymore.” –Mother
Cross cutting themes: limited resources and competing priorities
With respect to competing priorities, this was expressed as relating to both time and to the already limited resources. For example, many participants felt they could not supervise children because they needed to work in the field.“People spend the night there [in the same house with animals] because they lack the means … we don’t have the means to live in one house and have another house for the animals.” –Father
This arose in relation to other chores with parents stating, for example, that they might not have time to boil water because they needed to make dinner. They also noted that material items like soap and water might not be available for handwashing or diaper cleaning because they had instead been used for washing dishes or bathing.“This is the problem we have with keeping a child's hands clean—we can't stay with him all the time …You will go to the field and leave the child to eat and the child will rush to eat without washing his hands.” –Community leader
Component II – Intervention development and piloting
Methods
Dimension of IBM-WASH | Implications for Intervention Design |
---|---|
Contextual dimension | |
Physical environment: Outdoor and indoor spaces are soil/made from soil, making it difficult to separate children from dirt during play. | Playmats selected as an enabling technology to reduce children’s time spent in direct contact with soil. |
Roles and responsibilities: Because adult caregivers often work away from the home, infants and toddlers may be left in the care of school-age children (4–12 years). | Songs describing the danger of mouthing dirty things developed to make behavioral recommendations about keeping young children on playmats accessible to school-age children. |
Play between children: Children commonly play with “mud fufu” with each other, and younger children sometimes eat it. | Narrative illustration at the beginning of the module showing an older child making mud fufu and a younger child eating it, and then showing the younger child becoming ill. |
Psychosocial dimension | |
Dislike/perceived threat: Caregivers dislike when children mouth soil or dirty things because they will become ill or get “snakes in the belly”. | Pictorial instructions included in module describe the connection between mouthing dirty things and developing intestinal worms and/or diarrhea. |
Concern/fear: There is a concern that small children will be upset/afraid/feel trapped if they are left alone on a mat or in a play yard to play. | Selection of playmats over play yards as an enabling technology to reduce concern/fears of child feeling trapped or scared. Encouragement of caregivers to play with children on the playmat, making the playmat a happy place for children and families. |
Cost: There is a high perceived cost associated with children getting diarrhea. | Narrative illustration included in module describes the financial burden associated with a child who becomes ill from eating dirt. |
Existing habits: Children play with whatever they find in the yard; Caregivers are accustomed to putting children on the ground when they are busy with other activities. | Pictorial instructions included in module show how to build and provide children with safe toys made from local materials. Encouragement of caregivers to always place children on the playmat, inside or outside, to encourage habit formation. |
Technological dimension | |
Manufacturing/access: Commercial playmats and play yards are not manufactured in DRC, and not distributed to markets accessible to rural populations. | Candidate playmats identified from locally available, low-cost, already in-use materials. |
Strengths/weaknesses of hardware: Some caregivers prefer a plastic flooring playmat, because it is larger, more durable, and easier to clean than a rice bag. | Plastic flooring playmat selected as final enabling technology. |
Dimension of IBM-WASH | Implications for Intervention Design |
---|---|
Contextual dimension | |
Access: Most households have their own pit latrine, which may facilitate disposal of child feces in the latrine. | Encouragement to always dispose of child feces in the latrine, either using a hoe or leaves. Recommendation to bury feces if latrine not available. |
Roles and responsibilities: Because caregivers are busy with other tasks or away from the home, there may be a delay in removing feces from the yard. | Pictorial instructions included in module recommending the adult caregiver (e.g. mother) to dispose of all child feces from the yard as soon as they return to the home. |
Psychosocial dimension | |
Beliefs: Caregivers believe that feces of a breastfed infant have fewer microbes than the feces of a child who is eating solid food. | Narrative illustration included in module describes how an infant’s feces can carry microbes, and how other family members can become ill from these microbes. |
Disgust and dirt reactivity: Caregivers have a disgust reaction to child feces, consider them dirty, and want to remove them from the yard. | Reinforcement of these feelings by showing illustrations of intestinal worms in feces in the module. |
Existing habits: Caregivers accustomed to using a shovel or hoe to remove feces from the yard; Caregivers previously accustomed to digging small holes beside the latrine for young children to defecate in; Child potties not in-use, but cloth diapers common; Some caregivers throw water from cleaning diapers in yard. | Hoe promoted as the enabling technology to remove child feces and dispose of it into the latrine. Leaves promoted to remove feces if hoe not available. Pictorial instructions included in module reinforcing removal of child feces with hoe, plus instructions for cleaning hoe with detergent after disposal. Narrative illustration included in module describes the dangers of throwing water with feces in the yard. Recommendation that water from cleaning feces or diapers be thrown in the latrine (or buried). |
Technological dimension | |
Manufacturing/access: Child potties not available in markets accessible to rural populations. | Child potties not included as a candidate enabling technology. |
Convenience: Households typically have a hoe; households typically have a pit latrine. | Hoe promoted as the enabling technology to remove child feces and dispose into the pit latrine. |
Dimension of IBM-WASH | Implications for Intervention Design |
---|---|
Contextual dimension | |
Climate: Small animals (e.g. rabbits and guinea pigs) cannot be kept outside due to weather. | Hutches for small animals selected as an enabling technology to facilitate keeping animals close to home but separate from children’s playing/eating/sleeping spaces (i.e. hutch in or attached to kitchen). |
Theft: Theft of domestic animals is possible if they are left in the yard at night, contributing to the practice of keeping animals inside alongside humans (e.g. in the kitchen or bedroom). | |
Roles and responsibilities: Caregivers and other adults are away from home during the day, leaving animal feces around the home untended to throughout the day. | Pictorial instructions included in module recommend adults clean the compound daily (by sweeping) and clean the animal hutch a few times per week. Addition of a Composting Module. |
Household resources: Preference for keeping animals in a separate structure limited by household resources (e.g. space, finances). | Candidate animal hutches constructed from low-cost, locally available materials. |
Household income and food security: Animals provide an important source of nutrients and potential cash flow. | Narrative illustration included in module acknowledges the importance of animals and highlights the importance of keeping them safe by giving them a home (i.e. hutch). |
Psychosocial dimension | |
Cultural identity: There is a long history of living with animals in this community. Animals provide food and economic support. | |
Knowledge/perceived threat: Some animal feces are considered dirty and/or harmful for human health, others are not. | Narrative illustration included in module describes that all animals can carry germs that can make household members ill. |
Safety concerns: Concern that children will hurt animals by playing with them roughly if they are kept in close proximity to each other. | Narrative illustration included in module emphasizes the value of building a safe space for animals. |
Existing habits: Very few households keep guinea pigs in hutches, while some do keep rabbits in hutches. | Information included in the module about safely keeping guinea pigs in a contained space. |
Technological dimension | |
Manufacturing/access: Small, inexpensive animal hutches accessible to rural populations. | Candidate animal hutch design able to be built by household members from low-cost, locally available materials, used by some households currently. |
Dimension of IBM-WASH | Implications for Intervention Design |
---|---|
Contextual dimension | |
Theft: Theft of animal feces is possible, given their value for fertilizer. Some households keep feces in bags inside the kitchen or living space to avoid theft. | Pictorial instructions included in module recommend creation of a compost heap far from where children play. |
Livelihood/crop productivity: Animal feces are highly valued as agricultural fertilizer, resulting in opposition to dispose of animal feces in the latrine. | Narrative illustration included in module emphasizes the benefits of composting animal feces for generating fertilizer. |
Psychosocial dimension | |
Existing habits: Some households make compost for fertilizer from animal feces and/or food waste; most households put animal feces directly into the field after sweeping/cleaning to remove feces from the living area. | Pictorial instructions included in module recommend that feces be put in a compost pile with other household waste. |
Technological dimension | |
Manufacturing/access: Small, inexpensive compost piles accessible to rural populations. | Candidate compost pile able to be built by household members from low-cost, locally available materials, used by some households currently. |
Phase I
Phase II
Results
Protecting Children from Dangers in the Dirt Module
Pilot – Phase I
Caregivers also said their family members and neighbors noticed that the playmat was preventing children from putting dirt in their mouths.“Before finding this playmat, [the baby] often picked up dirt on the floor and ate it, but since I received this playmat, he no longer picks up the dirt.” – Mother
Some caregivers felt that their child was healthier after using the playmat.“My husband really appreciates the playmat and has said that it protects the child from dirt.”–Mother
Parents also mentioned that they tried to act on what they had seen in the flipbook.“[The child] is there [on the playmat] so he no longer eats dirt. This is what I observed as a change, and his health improved” –Mother
“In relation to the messages in the flipbook concerning these photos, I also forced myself to do what I had seen through these photos.”–Mother
Intervention refinement for pilot – Phase II
Pilot – Phase II
Caregivers reported cleaning the playmat when it was dirty, as they had been instructed to in the Care Group module. They also reported using the playmat while they were doing other chores.“Each day I used it all day, I would spread it out there in the field and the other kids would sit on it…or even when it's time to feed everyone, they sit there.”–Mother
Caregivers also mentioned that the playmat prevented food given to young children from dropping on the ground.“I can be preparing a meal or doing laundry and I’ll spread [the playmat] out and sit him on it.”–Mother
With the increased use of the playmats, some caregivers report that theirs tore. Many of these caregivers, however, said they were able to sew the playmats back together and continue using them.“I also liked it because there are times that the child can drop his food on the playmat and will take it back to eat it because there is no dirt. But if it falls on the ground, it becomes infected with microbes.”–Mother
Safe Child Feces Disposal Module
Pilot – Phase I
Pilot – Phase II
Caregivers incorporated lessons regarding disposal of wastewater from cleaning child feces and diapers into their daily practices.“I saw that it's good because there were so many mothers who removed [children’s] feces by throwing it in the cassava [fields] but according to the teachings you showed us, children’s feces belong in the toilet. I saw that these teachings were good and changed a lot of people.”–Mother
Participants were also able to remember information given about cleaning the tools used for feces disposal.“Before, when I finished washing diapers, I threw the first water in the toilet, and the rest in the yard. But your lessons told us that when we wash diapers, all the water must be brought to the toilet and that is what we do now.” –Mother
“I have a hoe, and before I would just throw the feces into the toilet, but your teachings showed me that when I’ve finished throwing away the feces, I should clean the hoe with soap or ashes.” –Mother
Hutches for Small Animals Module
Pilot – Phase I
Participants also said that the animal hutch kept animals from stealing food from household members.“The rabbit excrement, [the child] ate it but when [the rabbit] was placed in this [hutch], [the child] no longer does that.” –Mother
Some participants reported using the animal feces from their hutch to directly fertilize their fields or keeping the feces in a bag or pile for a few days, and then using them for fertilizer.“[The rabbit] steals the children’s food… he goes up… and takes the children’s food and eats. He is a thief and when he is in this [hutch] he no longer steals.” –Mother
Participants reported fertilizing fields close to their house, where children would sometimes play and could eat the discarded animal feces.“I shake [the animal hutch] and then the feces falls to the ground. Then I take the broom and something on which I want to collect dirt, and then I store the [animal feces] in one place. After a few days I put in the field.”–Mother
“I throw [the animal feces] in the onion field … my child eats it, what he sees is what he’ll eat …and [the field] is close.”–Mother
Intervention refinement for Phase II piloting
Pilot – Phase II
“[The children] played with [the guinea pigs] … they caught them all the time, but now [the children] don’t catch them anymore because [the hutch] was built for them. [When the children caught the guinea pigs] it wasn’t good because it happened that the [childern] killed [the guinea pigs].”–Mother
Some participants reported wanting to construct additional hutches in their homes for other animals. A participant who placed only her guinea pigs in the animal hutch said she wanted another hutch for her rabbits, so that the animals would each have their own space. Participants said that their neighbors were very curious about the hutches and inquired about having their own.“I see that [the animal hutch] is good because guinea pigs do not roam around the house as they did before. There were times that the guinea pigs ate the [human] food. You put the salt somewhere, they eat it… but now we have this hutch, we feel safe.” –Mother
“The model is very good because even the others who are from this neighborhood, when they arrive here, and they see it, they say, ‘that it is good!’ and want to know the person who made it.” –Mother
Composting Animal Feces Module
Pilot – Phase II
Participants with the compost piles said they noticed less animal feces and household waste on the household compound, and said that having a place to put animal feces and waste protected them against the spread of disease.“I had a serious problem when I swept, it bothers me - you sweep, and you don’t know where to put the [waste]. If you pile it somewhere, the chickens come and scatter it. I used to do this, if I sweep, for example, in the kitchen, I pile the waste in bags in one place, but as we built this compost I already feel free because I sweep, I collect the waste in a basket and I dump it into the compost. I have become comfortable because of the compost.” –Mother
Participants also mentioned that the compost pile was good for keeping children away from animal feces and household waste. Children were not able to play with the feces in the compost pile.“[The compost pile] saves us from microbes and dirty things (animal feces and household waste) because we pile all this in the compost and it will no longer spread on the ground, this saves us also from diseases.” –Mother
Most participants said the compost pile was easy to use and that they liked using the fertilizer for their fields. One participant mentioned that composting was better for the growth of their crops than throwing excrement in the field directly.“It is a good thing, because the children won’t be able to play [in the compost pile] with this waste because it’s kept in one place.” –Mother
However, some participants found it difficult to turn the compost heap. Participants also reported that they forgot or did not have the time to turn the compost pile.“Today I start to see that those who cultivate with compost benefit a lot from it compared to those who throw it directly in the field. There is a difference.”–Mother