Fecal pathogens (bacteria, protozoa, and viruses), soil-transmitted helminths, and other contaminants can enter the human body in multiple ways, causing intestinal infections, inflammation of the gut, or micronutrient deficiencies through reduced micronutrient absorption. The predominant and primary sources of fecal contamination include broken sewerage systems, open defecation, inadequate child feces disposal, and free-range livestock and poultry. Humans and animals easily walk on feces in open yards and, subsequently, introduce contamination to the household environment. Children spend a lot of time playing on the ground, often exploring their surroundings with multiple senses, including touch and taste. When children interact with their environment, they directly ingest contaminants like animal feces and soil from dirty fingers, toys, or other objects (Ngure et al. 2013), as well as human feces in the environment, as a result of poor sanitation. Clean play spaces can stop or minimize these modes of transmission (Mbuya and Humphrey 2016).
Even when children do not appear to be infected, their continued exposure to fecal contamination can affect growth and overall health through gut inflammation and subsequent chronic immune response that reduces energy and nutrients from growth and development (Humphrey 2009; Ngure et al. 2014). While it is still unknown how important this contamination pathway is for child health and anemia reduction, research is ongoing.
Clean play spaces separate children from contaminated soil, animals, animal feces, and human feces within the immediate household physical environment. While completely separating children from their environment might prevent them from ingesting fecal contaminants, it will also keep them from interacting with their surroundings—an important part of their developmental process. Therefore, interventions that improve hygiene in the spaces where children live and play should not block their developmental need to explore the environment (Mbuya et al. 2015; SPRING Project 2015).
Measurement and data sources
Ideally, structured observations of household hygiene practices and microbiological assays would be used to collect information on clean play spaces. Indicators for this intervention have not been adopted for regular data collection, and research surveys provide most of the available data. Programs that examine the relationship between environmental hygiene and stunting have used the following indicators, but carefully consider each one before including it in a monitoring or evaluation plan:
- percentage of households maintaining a clean environment (no standardized definition available) for children under 2
- percentage of households with children under 2 where human feces is not present inside the household compound
- percentage of households where animal feces are not present inside the household compound
- percentage of households where animals and children sleep in the same room or building, an indicator associated with higher stunting in Ethiopian households (Headey and Hirvonen 2015).
Other possible indicators include spot checks for—
- presence and number of free range poultry and livestock
- presence type and density of animal feces within the courtyard/household environment
- visibly dirty caregiver's hands
- visibly dirty child's hands.
In situations where a specific product, such as a mat or playpen, are introduced as part of clean play spaces interventions, you could collect data on sales/distribution, coverage, and use of the product.
- The lack of common indicators means there is no consensus on how to measure clean play spaces.
- Collecting data by observing household hygiene practices and conducting microbiological assays is expensive, can be impractical, and may change the behavior of the people being observed.
- Given the myriad cultural practices around childrearing and the expectations of children’s activity at an early age, different contexts will require different versions of an intervention to ensure children have clean feeding and play spaces. This variability may make it difficult for you to routinely collect data and to compare it across time and place.
Dodos, Jovana. 2017. “WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact through Integration of WASH and Nutrition Programmes.” Paris; France: ACF International. http://www.actioncontrelafaim.org/fr/content/wash-nutrition-practical-gu....
Headey, Derek, and Kalle Hirvonen. 2015. “Exploring Child Health Risks of Poultry Keeping in Ethiopia: Insights from the 2015 Feed the Future Survey.” Ethiopia Strategy Support Program Research Note 43. Washington, DC: IFPRI; Addis Ababa, Ethiopia: EDRI.
Humphrey, Jean H. 2009. “Child Undernutrition, Tropical Enteropathy, Toilets, and Handwashing.” The Lancet 374 (9694): 1032–35. doi:10.1016/S0140-6736(09)60950-8.
Mbuya, Mduduzi N. N., and Jean H. Humphrey. 2016. “Preventing Environmental Enteric Dysfunction through Improved Water, Sanitation and Hygiene: An Opportunity for Stunting Reduction in Developing Countries.” Maternal & Child Nutrition 12: 106–20. doi:10.1111/mcn.12220.
Ngure, Francis M., Brianna M. Reid, Jean H. Humphrey, Mduduzi N. Mbuya, Gretel Pelto, and Rebecca J. Stoltzfus. 2014. “Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy, Nutrition, and Early Child Development: Making the Links.” Annals of the New York Academy of Sciences 1308 (1): 118–28. doi:10.1111/nyas.12330.
Ngure, Francis M., Jean H. Humphrey, Mduduzi N. N. Mbuya, Florence Majo, Kuda Mutasa, Margaret Govha, Exevia Mazarura, et al. 2013. “Formative Research on Hygiene Behaviors and Geophagy among Infants and Young Children and Implications of Exposure to Fecal Bacteria.” American Journal of Tropical Medicine and Hygiene 89 (4): 709–16. doi:10.4269/ajtmh.12-0568.
SPRING. 2015. “The SPRING/Ghana 1,000 Day Household Approach.” SPRING-nutrition.org. https://www.spring-nutrition.org/about-us/activities/springghana-1000-da....
WHO. 2015. Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene. Geneva, Switzerland: WHO.