Starting Life Strong in Designing child-focused hygiene and nutrition interventions The interconnections of WATER SUPPLY, SANITATION, HYGIENE, & NUTRITION Childhood stunting (de ned as being too short for one’s age) has long-lasting impacts on children’s physical and cognitive development. These impacts, in turn, reduce productivity and compromise health well into adulthood. Stunting is a direct and largely irreversible result of inadequate nutritional intake on the part of both the mother and child, coupled with frequent infections and illnesses during the rst 1,000 days of a child’s life. The underlying causes include dietary de ciencies, lack of exclusive breastfeeding, as well as inadequate access to water and sanitation services, poor hygiene, and caregiver neglect. Stunting can be reduced only through concerted multisectoral action, an approach that the Government of the Lao People’s Democratic Republic (Lao PDR) has adopted. Key messages Poor water supply, sanitation, and hygiene (WASH) contribute to the childhood disease burden related to undernutrition To improve children’s nutritional intake and mitigate childhood stunting requires coordinated efforts focused on WASH services, infant-focussed education, and nutrition. Policy makers would do well to consider the indepth research connecting WASH services, hygiene practices, and nutritional outcomes. Asymptomatic gut infections, known as of handwashing—can e ectively eliminate many environmental enteropathies, are considered a key of the important fecal-oral transmission pathways cause of childhood stunting (Prendergast and Kelly in rural settings, complementary hygiene 2012). These infections are caused in part by interventions are still needed. For example, unhygienic environmental conditions. Therefore, a World Bank–funded study in Bangladesh found greater access to quality water supply, sanitation, that despite access to on-site sanitation, household and hygiene (WASH) during the early stages of life compounds’ contamination by human and animal has been proposed as an important pathway to feces remained widespread (Ercumen et al. 2017), reduced stunting (Humphrey 2009). likely due to poor waste disposal and hygiene practices. Yet large randomized trials conducted in low-income Complementary hygiene interventions, especially rural settings of Bangladesh, Kenya, and Zimbabwe those that focus on interrupting fecal-oral pathways show no e ect of traditional WASH interventions on of disease transmission among infants and young height-for-age z-scores in young children (Luby et al. children, are needed (Cumming et al. 2019). 2018; Null et al. 2018; Humphrey et al. 2019). These interventions are referred to as “Baby WASH” While these interventions—namely, improved water (Ngure et al. 2014). quality, improved on-site sanitation, and promotion Formative RESEARCH METHODOLOGY The Scaling-Up Water Supply, Sanitation and Hygiene Project (SWSSHP) is a US$25 million investment to improve WASH services in four northern provinces of Lao PDR. To inform the design of Baby WASH interventions to be delivered alongside general project interventions, a two-stage formative study was commissioned by the World Bank, with support from the Japan Scaling up Nutrition (SUN) Trust Fund. Research was carried out in collaboration with RANASMosler (www.ranasmosler.com) and Lao Social Research (www.laosocialresearch.com) in 2019–20. During the rst stage of the study, qualitative During the second phase of the research, a research was conducted to identify the primary quantitative survey was conducted in 616 fecal-oral transmission pathways in households households to collect information on the practices with young children, and to understand aspects of of these three behaviors and the factors driving health-related knowledge, norms, and beliefs that them. (These factors include health risk perceptions, inform hygiene practices. The methodology involved personal attitudes and beliefs, norms and attitudes, focus group discussions with health workers, village perceptions regarding the feelings and behaviors of leaders, and families; transect walks to observe others, and self-regulatory habits relating to village settings; photovoice recordings; and perceived ability and con dence.) individual interviews. The research identi ed three practices likely to reduce early childhood exposure The research looked at factors driving the choices to harmful pathogens and support healthy growth. of those who practiced each behavior regularly These were: (1) handwashing with soap before and those who did not. Based on these ndings, feeding a baby, (2) controlling babies’ mouthing a set of interventions was designed for a primary behaviors, and (3) exclusively breastfeeding babies audience of mothers and infants, as well as the in their rst six months. larger family unit Handwashing with soap Controlling babies’ Exclusive before feeding a baby mouthing behaviors breastfeeding Research findings and THE DESIGN OF INFANT-FOCUSED WASH INTERVENTIONS Handwashing with soap before feeding children Findings Planned interventions Survey respondents who reported themselves as relatively A series of caregiver meetings, household visits, and phone unlikely to practice handwashing before feeding a baby felt messages were recommended, focusing on building and that their behavior was consistent with that of their peers. using a handwashing station with soap, and delivering They were personally unconcerned by the feelings social behavior change communication (SBCC) on the associated with not washing with soap—for example, they bene ts of handwashing. In follow-up community meetings, did not feel disgust at unclean hands and they felt that each village would receive a certi cate featuring a written washing hands took a lot of e ort. Similarly, they were not commitment to secure handwashing facilities for all con dent they would be able to wash their hands at critical households in the village. times and were unsure they would even remember to do so. Importantly, they did not view handwashing as critical to the prevention of diarrhea in young children. Finally, societal norms did not carry much weight—they believed that important people in the village were not concerned if they washed their hands or not. Controlling babies’ mouthing behaviors Findings Planned interventions Survey respondents who were relatively unlikely to control A series of caregiver meetings, household visits, and phone the mouthing behaviors of their babies did not link this messages were recommended, focused on demonstrating behavior with the prevention of diarrhea, and felt little the presence of dirt on objects and the oor, along with personal responsibility for or con dence in their ability encouraging the building of playpens. These were also to to control such behaviors, or to even remember to do so. deliver SBCC on the health bene ts of controlling mouthing Also, in their view, important people in the village were behaviors to caregivers, and to secure commitments to not concerned with whether they controlled their babies’ encourage this hygiene practice from other family members. mouthing behaviors or not. Exclusive breastfeeding Findings Planned interventions Among many survey respondents, the link between One-on-one household visits were recommended exclusive breastfeeding and undernourishment, that would focus on encouraging mothers to overcome and its subsequent link to child health, was not understood obstacles to breastfeeding, deliver SBCC on the health and there was relatively little commitment and feeling of bene ts of exclusive breastfeeding, and secure responsibility to breastfeed in the rst six months after commitments from other family members to encourage birth. Further, mothers’ con dence in their ability to the practice. breastfeed at all times was low, especially among those with agricultural work responsibilities. Respondents who were relatively unlikely to practice exclusive breastfeeding did not view it as a societal norm. Integration with MULTISECTORAL CONVERGENCE PROJECTS The Baby WASH interventions developed through this research will be delivered alongside the SWSSHP and integrated into the World Bank–supported multisectoral convergence for nutrition projects in Lao PDR. These projects—spanning WASH, social protection, health, and agriculture—will deliver a package of nutrition-speci c and nutrition-sensitive interventions to the same households concurrently. Graphic on convergence projects, available from https://www.worldbank.org/en/country/lao/brief/multi-sector-convergence-approach-to-reducing-malnutrition-in-lao-pdr Figure 1. Integration of infant-focused WASH interventions with convergence projects Reinforcement Parallel delivery of project of project messages interventions across to the same projects households Baby WASH messages Delivery of delivered through Village Cleaning SBCC through multiple platforms Day, child growth various monitoring, and channels at the CCT registration village level provide platform for SBCC Note: CCT = conditional cash transfer; IPC = interpersonal communication; SBCC = social behavior change communication; WASH = water supply, sanitation, and hygiene. Following the delivery of the interventions, the research team will evaluate the adoption of Baby WASH behaviors among the target audience. Impacts on child nutrition will be measured jointly for the multisectoral convergence projects to capture the e ects of the various projects’ inputs. The results of the evaluation will be shared with the Government of Lao PDR, to inform choices on whether and how to use the approach in other settings with high rates of stunting. Conclusions and POLICY RECOMMENDATIONS The rst 1,000 days of a child’s life—spanning the period in utero to the age of two—is an important window of opportunity to start children on a path toward full physical and cognitive well-being. During this period, it is important that children grow up in households with safe drinking water supply and good sanitation infrastructure. Beyond expanding access to WASH services, the research outlined in this brief identi ed three behaviors likely to reduce early childhood exposure to harmful pathogens and support healthy growth in rural areas of northern Lao PDR. A representative survey was used to identify the factors driving these behaviors, and to design Baby WASH behavioral interventions accordingly. 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