Background Research exploring the unique exposure pathways to fecal pathogens for young children and innovative water, sanitation, and hygiene (WASH) interventions for susceptible pediatric populations is needed to reduce the burden of diarrheal diseases and stunting globally. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to 1) identify exposure pathways to fecal pathogens that are significant contributors to morbidity for young children in South Kivu, Democratic Republic of the Congo, and 2) develop and evaluate scalable interventions that reduce fecal contamination and exposure from these pathways. The formative research portion of the project sought to identify feasible and acceptable WASH interventions to modify behaviors found to be associated with diarrheal disease and impaired growth in our REDUCE cohort study. Methods Ninety-one semi-structured interviews, 6 focus group discussions, and a pilot study of 102 households were conducted during 24 months of formative research. Thirty-one interviews and six focus group discussions were conducted with caregivers, community health workers, and village leaders to explore existing WASH practices and to identify barriers and facilitators to WASH behaviors. Findings were organized using the Integrated Behavioral Model for Water, Sanitation and Hygiene to facilitate interpretation and identify determinants to Baby WASH behaviors in this setting. Care Group modules and enabling technology were developed based on exploratory findings and then revised during a two-part, iterative pilot study. Sixty interviews were conducted with participants in a pilot study of the REDUCE Baby WASH Care Group modules to learn about their experiences with the intervention. Results Six REDUCE Baby WASH Care Group modules were developed based on formative research findings and covered the following topics: 1) living with animals; 2) child mouthing of fomites and feces; 3) composting animal feces; 4) child feces disposal; 5) handwashing with soap; and 6) water treatment. Conclusion This study took a theory-driven and evidence-based approach to formative research and the development of the REDUCE Baby WASH Care Group modules. Intervention design focused on interrupting the exposure routes for infants and young children to fecal pathogens in the environment and promoting low-cost, low-burden Baby WASH behavioral recommendations and enabling technology. These developed REDUCE Baby WASH Care Group modules are currently being rolled out to over 1,000,000 beneficiaries in Democratic Republic of the Congo.

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objective The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program focuses on identifying exposure pathways to faecal pathogens for young children in the Democratic Republic of the Congo (DRC) and on developing scalable interventions to reduce faecal contamination from these pathways. methods A prospective cohort study of 690 participants was conducted to investigate the association between hand, food, and environmental faecal contamination and diarrhoeal disease prevalence among young children in Walungu Territory, South Kivu, DRC. A total of 1923 hand rinse, soil, food, object, surface, stored water and water source samples were collected during unannounced spot checks after baseline enrolment and analysed for Escherichia coli. Caregiver reports of diarrhoea were obtained from children < 5 years at a 6-month follow-up. results E.coli was detected in 73% of child and caregiver hand-rinse samples, 69% of soil samples from child play spaces, 54% of child food samples, 38% of objects and surfaces children were observed putting in their mouths, 74% of stored water samples, and 40% of source water samples. Children < 5 years with E. coli on their hands had significantly higher odds of diarrhoea at the 6month follow-up (odds ratio: 2.03 (95% confidence interval: 1.05, 3.92)). conclusion The cohort study findings from the REDUCE program have shown that child hand contamination is associated with diarrhoeal disease in rural DRC, and that there is high faecal contamination in child plays spaces and food. These findings provide evidence demonstrating the urgent need to provide clean play spaces for young children and interventions targeting hand hygiene to reduce paediatric exposure to faecal pathogens.

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A n estimated 500,000 deaths globally are attributed to diarrheal diseases each year among children <5 years of age (1). Enteric pathogens infecting the intestinal tract can cause diarrhea and reduce a child's ability to absorb nutrients, even when infections are asymptomatic, resulting in malnutrition and impaired growth (2,3). Globally, in 2021, a total of 149 million children <5 years of age were estimated to be stunted in growth (4). Enteric diseases can have longlasting effects; studies have found that early childhood enteric infections leading to unmet energetic demands for adequate brain development can result in adverse cognitive developmental outcomes later in life (5-7). In the Democratic Republic of the Congo (DRC), an estimated 45 million diarrheal episodes occur each year, contributing to 10% of deaths among children <5 years of age; 43% of children in this age group are estimated to have stunted growth (8)(9)(10).A recent study found that the presence of Akkermansia muciniphila, a commensal microorganism, in child fecal samples was associated with significantly less diarrhea and greater linear growth measured using height-for-age (HAZ) z-scores (Almeida et al., unpub data). We conducted this cross-sectional study as part of the Global Enteric Multicenter Study (GEMS) conducted in Mali, Kenya, Gambia, and Bangladesh. Additional prospective studies are needed, however, to investigate the association between A. muciniphila and child growth. Lactobacillus spp. have also been shown protective against enteric infections and associated with healthy gut microbiota composition (11-13). In a multicountry study, the presence of L. salivarius was associated with less Shigella-attributed diarrhea (14). Laboratory studies have found that L. salivarius can improve growth in animals ( 15), but no study has investigated this association in humans.The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) study focuses on identifying pathways of exposure to fecal pathogens that are significant contributors to diarrheal diseases for young children in the DRC, and on developing and evaluating scalable interventions to reduce fecal contamination from these pathways.