Open 2013: Impact of Hygiene Training and Promotions on Health Outcomes and Facility Usage in Urban Slums

Impact of Hygiene Training and Promotion on Health Outcomes and Facility Usage in an Urban

Slum

By Dr. Renée A Botta and

Dr. Karen C. Loeb University of Denver

Kenya & Kibera

• About 34% of Kenyans live in urban areas, with approximately 2.5 million living in Nairobi.

• The urban poor make up 55% of Nairobi’s total population and occupy 5% of the total residential land area.

• Kibera is an informal settlement situated on the southwestern part of the city of Nairobi.

• The square mile of Kibera comprises 11 villages and is home to over half a million people living in slum conditions of single rooms mostly made of mud and corrugated iron sheets.

Poor Sanitation, water quality and hygiene increase child mortality

• About 4 billion cases of diarrhea per year cause about 1.8 million deaths, mostly among children.

• Diarrhea is the second largest killer of children, accounting for approximately 21% of deaths of children under 5.

Kibera Informal Settlement (Nairobi, Kenya)

• Unsafe water, inadequate sanitation and poor hygiene cause 88% of diarrheal cases according to The World Health Organization (WHO).

• In Kibera, the mortality rate for children under 5 is 19%.

The average under-five child mortality rate

across eight informal settlements of Nairobi, Kenya, is 35% higher than the national figure. In some of the slums, child mortality rates are more than twice the rural figure.

Research indicates investment in hygiene promotion, sanitation and water services is the most cost-effective way to reduce child mortality. 

Every US$1 spent on improving water supply and sanitation produces economic gains of at least US$5 and perhaps as much as US$28, depending on local circumstances.

Adding hygiene promotion can double the impact of sanitation facilities alone

We believe the high failure rate for adequate wat/san is a direct result of settling merely for the construction of facilities as the desired outcome, which is why we use a multi-faceted approach that links entrepreneurship, business processes and planning, governance and hygiene promotion to improved access to water and sanitation. 

Our solution

Global WASHES is a community-based research collaboration of University of Denver (DU) faculty and graduate students, Nairobi-based water and sanitation organization Maji na Ufanisi, the Rotary Club of Denver Southeast, and faculty and students from universities in Nairobi.

Our first goal is to develop and test a model of sustainable and scalable water and sanitation (wat/san) facilities through research and capacity building in Kibera, an informal settlement in Nairobi, Kenya.

Our second goal is to maximally empower Kiberans as wat/san advocates, colleagues, entrepreneurs, and facility managers.

We have 8 facilities in the Silanga Village of Kibera, originally funded by a substantial 3-H Grant from Rotary International.

We also have new facilities funded by the Hungarian Embassy and the Swedish Embassy in another village in Kibera as well as an informal settlement in Mombasa.

We work with Community Health Workers (CHWs), which have been established by the Kenyan Ministry for Public Health & Sanitation, and with women’s groups and other community based organizations (CBOs).

Project Background

Areas of Research• Health and Hygiene Training

• Hygiene KAP (Knowledge, Attitudes, Practices)• Behavior Change with Theory• Hygiene Messaging• Health Communication• Income Generation as Hygiene Motivator

• Business Planning• Standard Operating Procedures• Project Management Oversight• Usage and Financial (E & R) Records• Break-Even Analysis for Enterprises• Positive Net Margin Drivers• Social Entrepreneurship and Social Franchising• Sustainability Assessment (3 P’s)

• Local Governance• Organizational Structure and Dynamics• Cooperation with Utilities• Geographical Mapping• Communication• Social Capital

Proper hand washing and water purification is imperative in reducing diarrhea and ultimately saving lives Research has shown proper hand washing can

reduce the incidence of diarrhea by 40% We sought to develop a campaign to promote the

adoption of hygiene behaviors known to reduce the incidence of diarrhea

One major problem with using social marketing behavior change campaigns in developing countries is that after the intervention is completed and researchers leave, the falloff rate for behaviors is very high.

Some researchers have suggested that sustaining healthy behaviors requires continuous monitoring and promotion, as well as ongoing community mobilization.

We suggest that linking entrepreneurial hygiene endeavors is another way to sustain behaviors

Hygiene Education & Promotion

Participatory, community influenced, train-the-trainer approach The facilities provide a platform for community-run hygiene trainings. Hygiene practices tend to fade once promotion ends; however, our model

incentivizes ongoing hygiene promotion and training Trainers motivated to continue training because can make money selling

liquid soap, water purification, and other hygiene-promotion related items.

Another key incentive for continuing hygiene practices is the reduction in diarrhea within the community and the associated socio-economic gain related to increased attendance at school and work.

Training includes: hygiene and health connections, hygiene practices in the community, hand washing songs, role playing for peer education and behavior modeling, making soap, making safe water storage containers, making hand washing stations, and making hygiene promotion messages.

Our Hygiene Promotion

• Formative research conducted to design the hygiene training to be tailored to the community indicated cost and control over the environment were the major barriers to practicing good hygiene

• Thus, we sought to reduce those barriers in sustainable ways

• Further, the research revealed liquid soap to be cost-effective to produce and a chlorine water pruification treatment to be cost effective to sell in individual doses

• Community health workers (CHWs) and community members were interested in exploring soap making and water purification sales as small business/microenterprise ventures.

Linking hygiene promotion to social entrepreneurship

Methods in Brief• Household surveys conducted to establish baseline and to learn

more about the community for tailoring the hygiene training• Baseline health data also collected from AMREF• Facilities (and thus neighborhoods around facilities) randomly

assigned• Training conducted• Messages printed, placed in facilities and given to CHWs • Post-test household surveys conducted as well as community

observations• 3 months after post-test household surveys conducted, post, post-

test household surveys conducted, as well as community observations

• Facility data collected monthly• Monitoring and evaluation continues• Health data from AMREF collected quarterly

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Self reported hand washing with soap at key times significantly increased pre to post test

More importantly, demonstrated proper hand washing also increased from pre to post test

When take into consideration treatment versus control facilities (because we randomly assigned training and soap sales by facility) Treatment facilities saw average 1 point improvement, whereas the

other five combined saw average 0.3 improvement – we expected some spillover given the size of the community

Water treatment went from 51% doing nothing and 21% using chlorine treatment to 32% using chlorine treatment (post) 18% doing nothing and 36% using chlorine (post, post)with 26% doing nothing. (change post to post post in doing nothing is mostly due to those who were boiling no longer doing anything) These are statistically significant changes.

Outcomes: hygiene practices

Health outcomes also improved pre to post Diarrhea rates dropped

Self reported and AMREF data AMREF data not able to tease out by facility so overall

for community compared to control villages Self reported diarrheal rates dropped more near

treatment facilities than other facilities Missed work rates dropped

Highest gains near treatment facilities Falloff? Looking at post versus post post

Small falloff but maintained signif increase from baseline

Outcomes: hygiene practices

Conclusions

Increased access to:• water purification• soap • hand washing stations• hygiene training• hygiene messaging • water• toilets

Improvements in:• Diarrhea rates• Perceived health• Missed work• Proper hand

washing• Water purification• Improved toilet

usage