Risk factors and transmission pathways to infection and malnutrition in infants in Ethiopia: implications for WASH programming.

In certain lower-income regions, poor infant health outcomes remain a key concern. These include diarrhoea and infection which can impede development. Water, sanitation and hygiene (WASH) interventions should block faecal-oral transmission and prevent infection from pathogenic organisms. However, interventions have focused on containing human faeces whilst overlooking the burden from domestic animals. Interventions also often neglect the age- and behaviour-related pathways to infection and are so not adequately tailored to mitigate it. This thesis sought to better understand the risk factors and transmission pathways to infant infection in Ethiopia and how a household playspace (HPS) might reduce this. Multiple methods were employed. Initially, a literature review examined the contribution of domestic animals to infant infection, malnutrition and household contamination. Following, two phases of formative fieldwork used environmental and clinical sampling, anthropometry, survey, and observational data to identify specific risk factors and transmission pathways contributing to infection in rural Ethiopian households. Important was the effect of keeping animals inside on maternal and infant hand and floor contamination (all p<0.005), and with infant stools positive for Campylobacter (p=0.027, OR 3.5). WASH facilities did not reduce contamination (p=0.76) nor the odds of infection (p>0.5). Concurrent fieldwork involved the design and build of an HPS to block key transmission pathways. Through a multi-stage, participatory design process, an HPS prototype was developed and trialled in a feasibility trial. This aimed to determine the feasibility of a definitive trial. The trial demonstrated good acceptance and adherence among intervention households and multiple secondary benefits, including on maternal time burden and infant injury prevention. Through multiple stages, this thesis describes the impact of animal faecal contamination on domestic hygiene and infant infection risk and how a WASH intervention component might mitigate this. Future interventions must consider age-specific needs and the importance of overall domestic hygiene to improve infant health.