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Revealing contamination pathways in informal settlements

How understanding the ways in which children are exposed to illness-causing pathogens can unlock more effective interventions.

Globally, about 500,000 young children die from diarrhoea each year. Children below five years living in low-income, high-density settings like informal settlements, have the highest risk of developing diarrhoea and other gastrointestinal illnesses due to their exposure to environmental contamination. While there are no easy solutions, RISE is undertaking research with the program’s participating informal settlement communities to better understand how children become exposed to contamination in their environments, and assess the impacts of the program’s water and sanitation intervention on these exposure pathways.

The research is investigating how children living in informal settlements interact with their environments in order to unravel the different contamination pathways that have the potential to expose children to gastrointestinal pathogens. This involves a combination of observing and assessing children’s interactions with their environment, and testing for faecal contamination and enteropathogens in the environment. One of the main goals is to generate a model that maps children’s exposure and their likely risk of illness, which will provide essential evidence on how interventions aimed at improving water and sanitation infrastructure should be designed and implemented in order for health improvements to be optimised.

Risk models have long been used to understand the likelihood of children getting sick. However, many rely on assumptions on the ways that children become exposed to contamination or examine surrogates of enteropathogens. RISE is investigating current uncertainties by systematically examining a range of faecal transmission pathways and by testing for a range of specific pathogens.

RISE teams in Fiji and Indonesia are conducting videography observation and coding children’s activities and surveying caregivers on their children’s day-to-day habits. Data will be overlayed with environmental samples that have been tested for faecal pathogens, as well as spatial information including areas where children spend their time.

The process of capturing these comprehensive risk variables comes with challenges. Videoing children in their ‘natural habitats’ is physical work demanded over many hours. Despite attempts to observe at a distance, children can naturally perform and try to interact with videographers. However, the film crews have been creative, ‘spy-like’, to remain inconspicuous.

The videos are coded using a software that has been customised for second-by-second recording of what a child places in the mouth, location and other behaviours of interest. Developing a consistent palette for coders to log the innumerable, unpredictable actions by children takes endless fine-tuning, workshopping, re-trialling in the field, and quality control.

Perhaps most importantly, great care and support is provided to caregivers and teams to feel comfortable working so closely with children and their families. RISE field teams undertook child protection training in advance of the videography campaigns. They then visited households to explain the research, gave reassurance of maintaining privacy, and kept communication lines open for questions to be asked at any stage. Fijian and Indonesian colleagues have guided research activities, ensuring they are culturally appropriate.

Two videography campaigns are complete in RISE settlements in Fiji and Indonesia, with foods and surface contamination sampling and analysis beginning in 2023. Researchers are hopeful that the rich amalgamation of data will tell a more comprehensive story of the relationship between children and their environments, so that interventions can materially improve their health outcomes in informal settlements, and beyond.

Videography observation of a child's activities in a RISE settlement in Suva, Fiji.