Stunting Free Villages, Bangladesh

Stunting Free Villages: Impact Monitoring of WASH Service Outcomes

Over the last decade, Bangladesh has made remarkable progress in sanitation coverage. The 2013 JMP report shows only 3% of the population practices open defecation, while 83% of the population have access to improved yet shared sanitation facilities. In contrast, malnutrition in Bangladesh still remains among the highest in the world. About 41% of children under five are stunted (low height for age), 16% are wasted (low weight for height) and 36% are underweight (low weight for age). Therefore, despite the great success in safe water supply and sanitation coverage, the expected health outcomes are yet to be realized. This takes a heavy toll on children’s health. Stunting (or chronic child malnutrition) can result in increased mortality risks and impaired cognitive function that potentially impacts future work productivity.

Previous knowledge on the relationship between WASH and child nutrition has always been mediated through diarrhea. However, recent evidence from 140 Demographic and Health Surveys (DHS) data sets from 60 countries reveals a strong correlation between open defecation density and stunting. This suggests that the reducing exposure to fecal contamination may have a greater impact on stunting than controlling diarrhea. One explanation could be a phenomenon known as Environmental Enteropathy where constant exposure to fecal contamination can infect the intestine causing the villi to contract thus reducing the absorption of nutrients often without any symptoms of diarrhea. The reduced capacity for nutrient absorption may lead to stunting.

Innovations:

Childhood stunting/wasting is associated with numerous inputs. It is difficult to distinguish their relative contribution. This project reverses the logic. That is, this project aims to engage with local communities to define the desired impact target (i.e. stunting free village). The project wishes to engage with communities as principal action researchers in measuring the eradication of stunting (and wasting) to identify which interventions are the most successful within the local context.

This approach is based on the success of the Community Led Total Sanitation (CLTS) movement. CLTS was able to create a desire and responsibility amongst citizens to create ‘open defecation free’ villages. Applying the same approach to the WASH and nutrition sectors may make it possible to trigger communities to create ‘stunting free villages’.

Targeting the eradication of stunting is founded on a collective realization that stunting among children <2 impairs their development. Regular and inclusive growth monitoring of all children and testing different actions (i.e. for breaking the fecal/oral links for children <2), may lead to stunting free villages. Behavioral changes by the households, as principal researchers, can contribute to global knowledge on nutrition.

The growth monitoring will be done by a mobile phone application specifically designed for this project. Each target child will have a unique ID. Height and weight of the child will be measured monthly and entered by using smart phones or regular mobile phones (SMS or voice). The data will be stored on a cloud database. Successful behavior interventions can be traced back to any specific household. Other households, as investigators, may then decide to emulate such behaviors. The internalization of the problem, a collective and individual determination for solving the problem, and individual and collective monitoring of the impacts will lead to a sustainable behavior change to fight stunting.