Towards transformative WASH: an integrated case study exploring environmental, sociocultural, economic and institutional risk factors contributing to infant enteric infections in rural tribal India

Abstract

Background Despite clear linkages between poor Water, Sanitation, Hygiene (WASH) and enteric disease, the design of effective WASH interventions that reduce child enteric infections and stunting rates has proved challenging. WASH factors as currently defined do not capture the overall exposure factors to faecal pathogens through the numerous infection transmission pathways. Understanding the multiple and multifaceted factors contributing to enteric infections and their interconnectedness is key to inform future interventions. This study aimed to perform an in-depth holistic exploration of the environmental, socio-cultural, economic and institutional context surrounding infants to develop an integrated understanding of enteric infection drivers in rural tribal Banswara, in Rajasthan State, India. Methods This study relied on the triangulation of mixed-methods to capture critical influences contributing to infant enteric infection transmission. We conducted structured observations and exploratory qualitative research across 9 rural tribal villages, including transect walks, household observations, interviews with frontline health workers and group discussions with mothers. The emergent social themes and identified factors were mapped based on the scale of agency (individual, family or community-level factor) and on their nature (environmental, socio-cultural, economic and institutional factors). Results Infants aged 5 to 24 months were seen to have constant exposures to dirt via mouthing of soil, soiled hands, soiled objects and food. Rudimentary household environments with dirt floors and domestic animals lacked a hygiene-enabling environment that hindered hygienic behaviour adoption. Several unsafe behaviours failing to interrupt infants’ exposures to pathogens were captured, but caregivers reported a lack of self-efficacy skills to separate children from faecal exposures due to the rural farming environments where they lived. Conceptual mapping helped understand how wider-level societal factors such as socio-economic limitations, caste inequalities, and political corruption may have trickle-down effects on the caregivers’ motivation and perceived self-efficacy for improving hygiene levels around children, highlighting the influence of interconnected broader factors. Conclusions Conceptual mapping proved useful to develop an integrated understanding of the interlinked factors across socio-ecological levels and domains, highlighting the role of wider sociocultural, economic and institutional factors contributing to infant’s enteric infection risks. Future WASH interventions are likely to require similar integrated approaches that account for the complex factors at all levels.

Measuring transformative WASH: A new paradigm for evaluating water, sanitation, and hygiene interventions

“…But there is a disproportionate outpouring of funding—from governments and NGOs—to drill wells, install pumps, and perfect all kinds of point‐of‐use and point‐of‐acquisition water safety technologies, which can be cynically viewed as the “WASH industrial complex.” Few (if any) of these solutions have been sustainably scaled beyond local communities, and they often lack clear evaluation criteria. Researchers at UCL have piloted concept mapping in rural India to embrace and gain a more holistic view of the socio‐environmental, cultural, and political‐economic context around infant health, but again focused on enteric infections (Vila‐Guilera et al, 2021). There are many confounders of the pathways and behavior changes associated with indicators like diarrhea and stunting (Smiley & Stoler, 2020).…”

“…Few (if any) of these solutions have been sustainably scaled beyond local communities, and they often lack clear evaluation criteria. Researchers at UCL have piloted concept mapping in rural India to embrace and gain a more holistic view of the socio-environmental, cultural, and political-economic context around infant health, but again focused on enteric infections (Vila-Guilera et al, 2021). There are many confounders of the pathways and behavior changes associated with indicators like diarrhea and stunting (Smiley & Stoler, 2020).…”

Impact of socioeconomic change and hygiene sanitation during pandemic COVID-19 towards stunting

“…excreta and animal waste exposure), and environmental sanitation (i.e. hand-washing with soap, boiling water) [21]. Some unsafe hygiene behaviors, defined as household hygiene and personal hygiene behaviors that may pose an additional risk of exposure to faecal pathogens and enteric infections in infants.…”

Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal

“…In addition to critical hygiene practices and the unsafe management of human faeces, the exposure to animal faeces in low-income settings is widespread and without safe management poses a threat to human health ( Matilla et al, 2018 ; Penakalapati et al, 2017 ; Prendergast et al, 2019c ). In particular, children below the age of 2 years living in household environments with dirt floors and domestic animals were observed to have constant exposure to dirt via the mouth ( Vila-Guilera et al, 2021 ). About one third of deaths among children under 5 years can be attributed to pathogens found in animal faeces ( Wang et al, 2016 ).…”