Table 1 Design of the Protecting Children from Dangers in the Dirt Care Group Module and Enabling Technology, Organized by IBM-WASH Dimension

 Physical environment: Outdoor and indoor spaces are soil/made from soil, making it difficult to separate children from dirt during play.

Playmats selected as an enabling technology to reduce children’s time spent in direct contact with soil.

 Roles and responsibilities: Because adult caregivers often work away from the home, infants and toddlers may be left in the care of school-age children (4–12 years).

Songs describing the danger of mouthing dirty things developed to make behavioral recommendations about keeping young children on playmats accessible to school-age children.

 Play between children: Children commonly play with “mud fufu” with each other, and younger children sometimes eat it.

Narrative illustration at the beginning of the module showing an older child making mud fufu and a younger child eating it, and then showing the younger child becoming ill.

 Dislike/perceived threat: Caregivers dislike when children mouth soil or dirty things because they will become ill or get “snakes in the belly”.

Pictorial instructions included in module describe the connection between mouthing dirty things and developing intestinal worms and/or diarrhea.

 Concern/fear: There is a concern that small children will be upset/afraid/feel trapped if they are left alone on a mat or in a play yard to play.

Selection of playmats over play yards as an enabling technology to reduce concern/fears of child feeling  trapped or scared.

Encouragement of caregivers to play with children on the playmat, making the playmat a happy place for children and families.

 Cost: There is a high perceived cost associated with children getting diarrhea.

Narrative illustration included in module describes the financial burden associated with a child who becomes ill from eating dirt.

 Existing habits: Children play with whatever they find in the yard; Caregivers are accustomed to putting children on the ground when they are busy with other activities.

Pictorial instructions included in module show how to build and provide children with safe toys made from local materials.

Encouragement of caregivers to always place children on the playmat, inside or outside, to encourage habit formation.

 Manufacturing/access: Commercial playmats and play yards are not manufactured in DRC, and not distributed to markets accessible to rural populations.

Candidate playmats identified from locally available, low-cost, already in-use materials.

 Strengths/weaknesses of hardware: Some caregivers prefer a plastic flooring playmat, because it is larger, more durable, and easier to clean than a rice bag.

Plastic flooring playmat selected as final enabling technology.