Reducing childhood illness - fostering growth : an integrated home-based intervention package (IHIP) to improve indoor-air pollution, drinking water quality and child nutrition

Child mortality attributable to pneumonia, diarrhoea and malnutrition accounts globally for the majority of 8.8 million annual deaths. More than half of these deaths are preventable. Available and effective interventions include safe water supply, household water treatment, improved chimney stoves and personal- and home-hygiene and -health messages. In Peru, the current health services reform is focused on shifting responsibilities to peripheral levels; thus, empowering community organisations to manage primary health care services, including health promotion and preventive measures at household level. The current political situation and policy framework to integrate effective preventive interventions that can be delivered at family level, prompted us to test the efficacy of a package of health interventions to reduce childhood illness burden at rural household level. The goal of this PhD thesis was to assess the efficacy of an Integrated Environmental Home-based-Intervention Package (IHIP), comprised of an improved chimney stoves, access to safe drinking water from solar radiation household water treatment (SODIS), and hygiene education interventions, to reduce morbidity of acute respiratory infections, diarrhoea and poor growth of rural Peruvian children under three years of age. We implemented a community-randomised control field trial (cRCT) in 51 community’s clusters of the San Marcos Province, Cajamarca Region, Peru. The cRCT was divided as follows: * Set-up, community selection and participatory intervention development: A pilot study was carried out for the selection of the interventions. These were adapted to local customs. The participatory phase is described in detail in Chapters 4 & 5. * Randomization, enrolment and baseline data collection: Chapter 6 describes the randomisation, enrolment and baseline in detail. * Carbon monoxide (CO) and Particulate Matter (PM2.5) household air quality assessment: Chapter 7 & 8 describe the efficacy of the OPTIMA-improved stove in improving household air quality in comparison to traditional open fire stoves. * Morbidity surveillance and field data acquisition: Morbidity data on the daily occurrence of signs and symptoms diarrhoea and respiratory illnesses of children was collected weekly. Anthropometric every two months and microbial data every 6 months. Chapter 9 describes the IHIP impact on morbidity reduction. * Workshops for a community-driven sustainable dessimination: Chapter 10 describes the community workshops and dissemination processes and dynamics within a socio-ecological framework. Our community-randomised control trial demonstrated that IHIP reduced 22% per year of child diarrhoea (RR 0.78, 95% CI: 0.49-1.05) and found an odds ratio of 0.71 for diarrhoea prevalence (OR 0.71, 95%, CI: 0.47, 1.06). No effects on the frequency of acute lower respiratory infections (RR 0.99, 95% CI: 0.59, 1.65) or child’s growth rates were found when comparing study arms. We identified three reasons for this moderate diarrhoea reduction: i) hand-washing promotion was universally found in our setting, since it is being promoted by the health care centre; ii) SODIS compliance was moderate: only one third of the beneficiaries were using the method regularly; and iii) the increased awareness for the child’s needs linked to the control intervention, could induce improved child care behaviour. The lack of effect on ALRI, could be linked to insufficient reduction in exposure to household air pollutants and high health service utilisation due to cultural beliefs and health seeking behavoiur. The household air pollution assessment study revealed only moderate reductions of 45% and 27% reduction of PM2.5 and CO, respectively for mothers’ personal exposure. This result was achieved in the best working stoves only. This may most likely not be sufficient to reduce impact on physician-diagnosed pneumonia. Community participatory meetings and surveys revealed that people’s decisions on adopting household-level environmental and hygiene interventions, was not only based on individual perceptions of their potential gains, but also depended on peer pressure and social network relations. Individual perceptions regarding pollution levels of water and household air (transparent, odourless water vs dirty air environments) influenced perceived gains and the adoption of certain interventions. Access to information and encouragement from health-care providers and programme implementers also increased adoption. The IHIP had several additional benefits beyond health outcomes. Mother’s expressed that the stoves could reduce cooking time and wood consumption, which translated into cost saving. They also could perform other task while cooking. Regarding the kitchen sink, the mothers expressed it facilitated handwashing, and washing of utensils with detergent, generating a cleaner kitchen environment that fostered home and food hygiene. We believe that the IHIP package motivated families to improve the kitchen living area in general. The high acceptance and sustained use was not only observed in the IHIP families but also in non-participating families that had copied the OPTIMA-improved stove after the community engagement in the desimination activities. We can also conclude that the IHIP package added to the family status, improved quality of life and impacted on their livelihoods, by empowering the beneficiary families. In conclusion, through this project we envisaged to demonstrate how an integrated package could be implemented at the household level in rural areas of Peru and its effect on health, quality of life and livelihoods. However, behaviour change for keeping maintanence of the interventions and use is necessary to achieve compliance, replication and sustainability

Community perceptions of health and rodent-borne diseases along the Inter-Oceanic Highway in Madre de Dios, Peru.

BACKGROUND: Madre de Dios is located in the southeastern Amazonian region of Peru. Rodents have been estimated to be the reservoirs for up to 50 % of emerging zoonotic pathogens, including a host of viruses, bacteria, and parasites. As part of a larger study involving both human and animal research, this study serves to obtain a broader understanding of the key challenges and concerns related to health and rodent-borne illnesses from the perspective of the people living in these communities. METHODS: We used a mixed methods approach, which comprised of 12 focus group discussions, 34 key informant interviews and the application of a survey (n = 522) in four communities along the Inter-Oceanic Highway (IOH) in Madre de Dios, Peru over a two-year period. RESULTS: Although 90 % of survey respondents answered that rodents can transmit diseases and had seen rodents in their homes and immediate surroundings, most could not name specific rodent-borne diseases and, when probed, described rodents as pests or nuisance animals, but were not concerned about acquiring illnesses from them. Key informant interview data suggests that there has been a perceived increase in the amount of rodents in the communities since the construction of the IOH, however this potential increase was not coupled with increased knowledge about diseases or perceived risks among these key informants. Health providers also mentioned a lack of diagnostic tools specific for rodent-borne illnesses. This may be related to the fact that although a common rodent-borne disease like leptospirosis is frequently detected in the region, it is not routinely and readily diagnosed, therefore the real burden of the disease and exposure risk can be underestimated. If rodent-borne diseases are not on the radar of health professionals, they may not consider presumptive treatment, which could result in unnecessary morbidity and mortality. CONCLUSION: Awareness of rodent-borne diseases is still lacking in the area, even among health care professionals within the communities, despite the known burden of diseases like leptospirosis. We expect to report further findings as we obtain more information from all the study components