This document proposes an intervention to combat child stunting in rural northern India through improved sanitation. It involves assessing village resources and sanitation practices, determining exposure pathways for stunting microbes, and mobilizing communities through religious figures and women's groups. Interventions include infrastructure improvements, hygiene education in schools, and partnerships with NGOs. The project would be implemented in four villages in Mahoba district over four years and evaluated through health assessments and questionnaires. If successful, the program aims to expand to other districts and involve university students long-term to sustain hygiene behavior change.

1. Resolving The Asian Enigma
Sapha
Sara Johnson | Katherine Hymel
Sara Liaghati-Mobarhan | Jessica Sidhu 1

2. Even with
adequate caloric and nutritional
intake, lack of sanitation inhibits growth.2

3. Stunting
• Low length- or
height-for-age
• Consequence of
multiple factors
often linked to
poverty
• Can lead to
developmental
problems and is
often impossible to
correct, but can be
prevented
GROWING UP EDUCATION
VICIOUS CYCLEPROFESSIONAL LIFE 3

4. “India’s stunting
problem represents
the
largest loss of
human
potential
in any country in
history, and it affects
20 times more people
in India alone than
H.I.V./AIDS does
around the world.”
Ramanan Laxminarayan
Vice president for research and policy at
the Public Health Foundation of India
4

5. Uttar Pradesh
RELIGIONS | Hindi,Urdu,Bhojpuri, Awadhi
LANGUAGES | Hindi, Urdu
POPULATION | 211,797,459
REGIONAL | 75 districts
Literacy rate: 70%, below national average of 74%
Key industries: IT, Agro Processing, Tourism, Mineral-based industries and Textiles
UTTAR PRADESH (UP)
5

6. 78% of people in UP practice open defecation (OD)
Poor sanitation spreads infections
Rapid escalation with population growth
OPEN DEFECATION IN UP
6

7. Far from his dwelling let him remove urine (and ordure), far
(let him remove) the water used for washing his feet, and far
the remnants of food and the water from his bath.
PURITY AND POLLUTION
7

8. CURRENT STRATEGIES
Total Sanitation Campaign(TSC)/Clean India Campaign
Change social norms and reduce OD
Nirmal Gram Puraskar monetary award for “open defecation free”
cities
Generational resistance
Constructed latrines in disuse
8

9. IMPLEMENTATION BARRIERS
Only 26% surveyed gave link between diarrhea and
infectious agents
Scientific misconceptions
OD associated with strength, rising early
9

10. Objective
Combat child stunting in rural regions of
northern India through assessment of each
village’s resources, mobilizing the
community through religious figures to
educate women and children on minimizing
exposure to growth-stunting microbia
10

11. Intervention overview
• Strong community assessment using
“triggering” phases to determine current
sanitation infrastructure and practices
• Determination of exposure pathways
• Community mobilization with educational
programs/appropriate technologies to
minimize exposure to those pathways
11

12. Initiative timeline
COMMUNITY
ASSESSMENT
EXPOSURE
ASSESSMENT
HEALTH
ASSESSMENT
COMMITTEE
MOBILIZATION
HYGIENE
TECHNOLOGY
SOLUTIONS
SCHOOL
CAMPAIGNS
SUSTAINABILITY
EVALUATION
ASSESSMENT
MOBILIZATION
SUSTAINABILITY
EVALUATION
FUTURE PLAN
APPRAISAL
1 . Mar . 2015 1 . Mar . 2016 1 . Mar . 2017 1 . Mar . 2018
12

13. Defecation area
transect walk
Community
mapping
Specific
questions about
defecation
behaviors
Community assessment
13

14. Exposure assessment
• Exposed groups potentially at riskWho?
• Directly and indirectly exposedHow many?
• Point of exposure in sanitation
systemWhere?
• Routes (direct, water/food sources,
mosquito breeding)Which?
• Frequency of exposure (daily,
weekly)How?
• Likely dose of exposure and typeWhat?
14

15. Exposure pathways
Source: Engineers Without Borders
15

16. Quantitative microbial risk
assessment
16

17. Infrastructure assessment
Access to
improved
water source?
Yes
Access to
latrine?
Yes
Is latrine in
use?
NoYes
No
No
17

18. INFRASTRUCTURESANITATION
INFRASTRUCTURE
SANITATION
COMMUNITY DEVELOPMENT
COMMUNITYDEVELOPMENT
18

19. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Community development
19

20. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Identify community leaders
• Female empowerment: most direct link to
children
• Involve religious leaders
• Provide with concrete tools (Facilitator’s
Manual, infrastructure and education
guidelines)
20

21. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Public health committees
• Host programs for women on basic
hygiene science and practices
• Monitor project implementations
• Seek input of community with
interventions
21

22. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Primary schools
• Introduction of basic hygiene lessons
• Interactive demonstrations
• Partnerships with pre-existing work:
• Hope for Hapric
• UNICEF, TSC
• Tippy Tap
• Sulabh School Sanitation Club
• Swacch Express
• Feedback Foundation
22

23. Primary
school
interventions
Handwashing with soap at critical
times can reduce diarrhea rates
by approximately 40%
INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
23

24. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Partnerships with NGOs
Sulabh International, Engineers Without Borders
24

25. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Bank filtration, managed aquifer recharge
Pumps, wells, spring boxes, gravity systems
Rainwater harvesting, micro dams
25

26. Monitoring and evaluation
• Adapted from Patil et al., 2014; see
appendix
• Measured Outcomes (questionnaires,
waste disposal classification, testing of
drinking water, child anthropometry and
specimen testing)
• Frequency: 2 times per year
• Award: Monetary incentives for villages
26

27. Projected community
• Mahoba district
• Population: 876,055
• 78.84 % population of Mahoba districts lives in
rural areas of villages
• Literacy rate: 65.27%
• Total child population (0-6): 128,129
• Four villages of focus
• Akona
• Jaitpur
• Rawatpura
• Salat
27

28. Hypothetical assessment
• Highest risk exposure pathway: ingestion
of excreta (fecal to hand to mouth)
• Latrines built by government but not in
use
• Access to food and water
28

29. INFRASTRUCTURESANITATION
INFRASTRUCTURE
SANITATION
COMMUNITY DEVELOPMENT
COMMUNITYDEVELOPMENT
29

30. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Not a major concern according to assessment
Latrines in disuse
30

31. Primary
school
interventions
Projected diarrhea
reduction rates by
approximately 40%
INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Tippy taps constructed at schools
and near identified areas for open
defecation 31

32. INFRASTRUCTURESANITATIONCOMMUNITYDEVELOPMENT
Community development
• Public health committee established
• Handwashing demonstration with women
and school children
32

33. Partnership with candidates during election season
Expansion of program into other districts
Involve university students
FUTURE PLANS33

34. SUSTAINABILITY
Cultural awareness
Avoidance of proprietary breakdowns
Community members fuel the movement
34

35. Budget
35

36. References
Badham J, Sweet L. (2010). Stunting: an Overview. Sight and Life. Retrieved on February 3, 2015 from:
http://www.sightandlife.org/fileadmin/data/Publications/Stunting/Stunting_An_O verview.pdf
Banda, K., Sarkar, R., Gopal, S., Govindarajan, J., Harijan, B., Jeyakumar, M., … Balraj, V. (2007). Water handling, sanitation and defecation practices in rural southern India: A
knowledge, attitudes and practices study. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(11), 1124-1130.
Coffey, D., Gupta, A., Hathi, P., Khurana, N., Srivastav, N., & Vyas, S. (2014, September 20). Revealed preference for Open Defecation: Evidence from a new survey in rural North
India. Economic & Political Weekly, 43-55.
Curtis, V., & Cairncross, S. (2003). Effect of washing hands with soap on diarrhea risk in the community: a systematic review. Lancet Infectious Diseases 3, 275–81.
Greater Access to Cell Phones Than Toilets in India: UN – United Nations University. (2010, April 14). Retrieved February 7, 2015, from http://unu.edu/media-
relations/releases/greater-access-to-cell-phones-than-toilets-in-india.html
Harris, G. (2014). Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition. The New York Times. February 5, 2015 from:
http://www.nytimes.com/2014/07/15/world/asia/poor-sanitation-in-india-may- afflict-well-fed-children-with-malnutrition.html
Mahoba District : Census 2011 data. (n.d.). Retrieved February 6, 2015, from http://www.census2011.co.in/census/district/540-mahoba.html
Mehrotra K. 2014. India’s Toilet Race Failing as Villages don’t Use Them. Bloomberg. Retrieved November 13, 2014 from: http://www.bloomberg.com/news/2014-08-03/india-s-toilet-
race-failing-as- villages-don-t-use-them.html
Quantitative Microbial Risk Assessment (QMRA) Wiki. (n.d.). Retrieved February 6, 2015, from
http://qmrawiki.canr.msu.edu/index.php/Quantitative_Microbial_Risk_Assessment_(QMRA)_Wiki
Singh, P., Chavan, P., & Mathur, D. (2013, August 10). Policy Brief for Parliamentarians, Open Defecation: This is also your business! Retrieved February 7, 2015, from
http://www.clraindia.org/include/ODpolicybriefFinal.pdf
The Sphere Project (2010). Minimum standards in water supply, sanitation, and hygiene promotion. The Sphere Handbook, 51-102. Retrieved from: http://my.ewb-
usa.org/theme/library/myewb-usa/project-resources/technical/SphereHandbook-Chapter2.pdf
Sulabh International Social Service Organisation. (n.d.). Retrieved February 5, 2015, from http://www.sulabhinternational.org/
Tippy Tap. (n.d.). Retrieved February 4, 2015, from http://www.tippytap.org
WaterAid (2011). Technology Notes. Retrieved from: http://my.ewb-usa.org/theme/library/myewb-usa/project-resources/technical/water_aid_technology_notes.pdf
WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Progress on Drinking Water and Sanitation: 2014 Update. Retrieved February 6, 2015 from:
http://www.wssinfo.org/fileadmin/user_upload/resources/JMP_report_2014_webE ng.pdf 36

37. Hope for Hapric
• Campaign within
primary schools to
promote good
facilities, build
hygiene behaviors,
and educate students
interactively on
WASH access
• Partnership with Save
the Children
Primary schools
37

38. UNICEF’s Child Environment
Program
• WASH in school
interventions that
promote hygiene
behaviors
• Supports
government TSC
and National Rural
Drinking Water
Programme
Primary schools
38

39. Sulabh School Sanitation Club
• Composed of students,
both boys and girls,
ranging from 10 to 16
years of age
• Responsible for looking
after the school’s water
and sanitation facilities,
and spreading hygiene
messages among their
peers.
Primary schools
39

40. NGO: Swacch Express
• Passes through villages
in urban and rural
villages throughout
India (including UP)
• Creates awareness
around hygiene and
sanitation through
interactive videos, flyer
distributions, posters,
hand-washing sessions
and street plays.
Primary schools
40

41. Feedback Foundation (Partnership)
• Community engagement entity that could
partner with us to train university students and
community leaders/members to do work in
schools and communities
• Led a capacity building effort that “Trained the
Trainers” of the community-led Total
Sanitation Approach in rural areas
Primary schools
41