Gwama-Thesis final ppt. EFFECTIVENESS OF COMMUNITY- LED TOTAL SANITATION ACTIVITIES ON SELECTED HEALTH OUTCOMES AMONG CHILDREN AGED BELOW 5 YEARS IN KINANGO SUB-COUNTY, KWALE COUNTY .

ABSTRACT
A third of the population globally do not have access to water and sanitation. In
Kenya, 55% of the total population does not have access to water and proper
sanitation. This has contributed to sanitation related morbidity and mortality among
children below the age of 5 years. In an effort to address the problem the
Community-Led Total Sanitation (CLTS) approach has worked well in various set
ups. This study aimed to determine the effectiveness of CLTS on selected health
outcomes (nutrition status, diarrhea and anemia) among children aged below 5 years
in Kinango Sub-County, Kwale County, Kenya. This was a quasi-experimental
comparative study with intervention (CLTS among 405 households in 5 villages)
sites and control (non-CLTS among 402 households in 5 villages) stes.
Anthropometric and haemoglobin measurements were undertaken at baseline and
end-line. In addition, an entry and exit questionnaire was administered to collect data
on socio-demographic characteristics, knowledge on CLTS practices and on the
frequency of experiencing diarrhea among the children <5years. Qualitative data
were collected through key informant interviews (KIIs) and Focus group discussions
(FGDs). Data were analyzed using SPSS IBM version 22.0. Descriptive statistics
were used to explore insights in data. Association between variables was assessed
using both chi-square and multivariate logistic regression analysis. The mean
difference of health outcomes between CLTS and non-CLTS sites was done using
Chi-square test. Binary logistic regression and Poisson regression were used to
identify predictors of latrine ownership and morbidity. Qualitative data was
summarized using thematic analysis. At baseline survey, out of 402 children, 181
(40.02%; 95% C.I=40.1-50.0) were malnourished in the control group while 221
(54.98%; 95%C.I=50-60) had no malnutrition. On the other hand, out of 405 children,
173 (42.72%; 95%C.I:37.8-47.7) had malnutrition while 232 (57.28%; 95%C.I:52.3
62.2) had no malnutrition. There was no significant difference in nutrition status for
children in the control and intervention group (χ2=0.44, df =1, p=0.55) at baseline.
Chi-square statistics indicated that there were significantly (χ2=31.2, df =1, p=0.00)
more children without malnutrition among the intervention group compared to the
control group at end-line. Morbidity for diarrhea was assessed among children below
5 years. At baseline, 230 (57.2%; 95% CI: 52.36-62.04) out of 402 children in the
control arm were reported to have experienced diarrhea in the last 2 weeks while 172
(42.8%; 95% CI: 37.96-47.63) had no reports of diarrhea. During the same period,
213 (52.6%; 95% CI: 47.74-57.66) out of 405 children in the intervention arm were
reported to have experienced diarrhea in the last 2 weeks while 192 (47.4%; 95% CI:
42.54-52.26) had no reports of diarrhea. Hence, there was no significant difference
(χ2=3.083, df=1,p=.079) in the occurrence of diarrhea am

1. EFFECTIVENESS OF COMMUNITY- LED TOTAL SANITATION ACTIVITIES ON SELECTED HEALTH OUTCOMES AMONG CHILDREN AGED BELOW 5 YEARS IN KINANGO SUB-COUNTY, KWALE COUNTY . FRANCIS GWAMA MWATSAHU HSH411-C005-5056/2016 Supervisors: Prof. Simon Karanja (JKUAT) Prof. Mohamed Karama (UMMA) Prof. Michael Zimmermann (ETH) Dr. Calvin Otieno (JKUAT)

2. Community-Led Total Sanitation (CLTS) process CLTS ensures collective community decision & local actions which does not depend on external subsidies and prescriptions Natural Leaders emerge from collective local actions who lead future initiatives towards open defecation free (ODF). Elimination of OD reduces episodes of malnutrition and anemia 3 rd Party ODF Certification Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 2

3. Global prevalence of Open Defecation (OD) Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 3

4. African prevalence of OD Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 4

5. 4.7 Million people practice OD in Kenya 7.3% of HHs lack sanitation facilities in Kenya translating to nearly 4.7 million people practice open defecation (KNBS, 2019). 5 Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities

6. Regional v ariation on prevalence of OD in Kenya 85 % of OD in Kenya takes place in 15 counties Baringo, Garissa, Homa Bay, Isiolo, Kajiado, Kilifi, Kwale, Mandera, Marsabit, Narok, Samburu, Tana River, Turkana, Wajir and West Pokot (KNBS, 2019) Six counties have rates exceeding 40%. 31.7% HHs defecate in the open in Kwale Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 6

7. OD remains the norm in Turkana (82.2%), Wajir (76.7%), Samburu (73.4%) and Kwale (51.2%). ATORS AND KENYA’S SCORE 16% % National OD rate ODF free counties 3 19 Million Kenyans lack access to improved sanitation 8.2% Diarrhea cases in Kwale Diarrhea in Kinango 11.2% of OPD cases WASH-related conditions (e.g.; malnutrition, anaemia ), are the number one cause of under-5 hospitalization and mortality. Tools and policies have been developed (KESH Policy 2016/2020, KESSF 2016/2020, NOK 2016/17-2019/20, COCAPs 2020). Statement of the Problem Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 7

8. Justification GoK had committed itself to achieve Kenya ODF by 2020 as per as the ODF Road Map 2020. Rapid acceleration of efforts needed to achieve 100% ODF Kenya by 2020. MoH recommended the need to undertake a study on factors hindering utilization of CLTS approach leading to low levels of sanitation within counties (MOH, 2010). Current study seeks to determine potential associations between health outcomes and improved sanitation through CLTS approach Study findings informing county policy-makers, on the effectiveness of CLTS activities on selected health outcomes of children aged below 5 years in Kinango Sub-County, Kwale County, Kenya. 8 Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities

9. Objectives Broad objective: To determine the effectiveness of community-led total sanitation activities on selected health outcomes of children aged below 5 years in Kinango sub-county, Kwale County. Specific Objectives Key outcomes measures 1. To determine the effect of CLTS on nutritional status of children aged below 5 years in Kwale County % of children with no malnutrition define as… 2. To determine the episodes of diarrhea and URTIs in the last 6 months among children aged below 5 years in CLTS implementing sites and non-CLTS implementing sites in Kinango Sub-County, Kwale County. -reduced diarrhea cases measured by % of children experiencing diarrhoea episodes in the last 30 days? 3. To determine the effect of CLTS on anaemia among children aged below 5 years in Kwale County -% of children not anaemic 4. To determine the ownership of latrines and practice of open defecation among household members in CLTS implementing sites and non-CLTS implementing sites in Kinango Sub-County, Kwale County. -increased number of latrine constructed measured by% of households with latrines 5. To determine the socio-cultural barriers, level of awareness and practices towards CLTS among household members in CLTS implementing sites and non-CLTS implementing sites in Kinango Sub-County, Kwale County. -increased proper utilization of latrines -increased knowledge of CLTS Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 9

10. Conceptual Framework 10

11. Materials and methods Study site Kwale County has a total of 1258 vijijis (173,176 HHs), only 195 ( 16% ) vijijis (112,564 HHs)-certified. Latrine coverage- 51.2%. Kinango Sub-County has a total of 509 vijijis (40,390 HHs), 50 ( 10%) vijijis (19,814 HHs)-certified. Latrine coverage- 49%. Samburu-Chengoni ward has 2 village units (VUs): Kinagoni village unit with a total of 12 vijijis - ALL certified ODF. Chengoni VU [study site] has 10 vijijis – ALL OD. 11 Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities

12. Materials and methods Cont … Study design : Quasi Experimental study using a Pre-Post approach Study population : Children aged <5 years and their parents / guardians Sample size : based on differences in two proportions (Wang, 2007); n = (Zα/2+Zβ) 2 * (p1(1-p1)+p2(1-p2)) / (p1-p2)2 n = Sample size in each group (assumes equal sized groups) Zα/2 = the desired level of statistical significance (typically 1.96 for 5% level of significance) Zβ = the desired power (typically 0.84 for 80% power). p1-p2 = effect size i.e. reduction in diarrhea due to CLTS, set at 10%. n = (1.96+0.84)2*(0.55(1-0.55) +0.45(1-0.45))/(0.1)2 n = 388.08 (approximately = 388 HHs per arm) Plus 10% for non-response (39) n=427 per arm giving a sum of 854 Data collected among 402 and 405 respondents in comparison and intervention sites respectively 12

13. Maps of intervention and control sites 13 Total of 10 villages within Chengoni village unit (5 intervention- Bofu , Makamini,Chanzou I, Chanzou II and Dambale with 2457 households and 5 control villages- Chengoni A, Chengoni B, Mtulu , Mwakunde and Mwanzungi with 2198 households

14. Ethical considerations Study commenced after approval by the Pwani University Ethics Review Committee County Government of Kwale (Dept. of Health Services) was informed about the study prior to execution and progressive feedback has been provided throughout the research process Oral informed consent was obtained from all respondents Confidentiality was observed by ensuring proper cross-referencing, listing 14

15. Data Collection Procedure 15

16. Data Analysis Procedure Descriptive Statistics was used to summarize the data Student T tests (unpaired) was used to determine if there was a significant difference in the means of children with malnutrition and Anemia at baseline and end term surveys respectively Chi 2 statistics was used to cross tabulate nutritional status and anemia in children <5 years. Bivariate and multivariate regression analysis was used to establish determinants of latrine ownership. 16 Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities

17. Group Baseline survey End-line survey With Malntr Freq (%) No Malntr Freq (%) χ 2 -value df P-value With Malntr Freq (%) No Malntr Freq (%) χ 2 -value df P-value Control 181 (40.02) 221 (54.98) 0.35 1 0.55 195 (48.51) 207 (51.49) 30.2 1 0.00 Intervention 173 (42.72) 232 (57.28) 119 (29.38) 286 (70.62) 17 Objective 1: Nutrition status of children < 5 years in the control and intervention sites at baseline and end-line of the survey Results

18. 18

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20. Objective 2. Proportion of children <5yrs with diarrhea in the control and intervention sites at baseline and end-line Group Baseline End-line Diarrhea status Chi 2 df P-Value Diarrhea status Chi 2 df P-Value + ve Freq (%) - Ve Freq (%) + ve Freq (%) - Ve Freq (%) Control 230 (57.4) 172 (42.8) 1.73 1 0.079 198 (49.2) 204 (50.3) 42.73 1 0.001 Intervention 213 (52.6) 192 (47.4) 109 (26.9) 296 (73.1) 20

21. Objective 2: Episodes of diarrhea within the last 6 months among children aged below 5 years There was no significance difference in the proportion of children with diarrhea at the baseline survey in both the control and intervention groups (χ 2 =1.73,df=1,p=.079). In the intervention sites, the proportion of children < 5yrs with diarrhea was significantly lower than those in the control group (χ 2 =42.73, df =1, p<.001) at end-line 21

22. 22

23. Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 23

24. Group Baseline survey End-line survey Anemic Freq (%) Not anemic Freq (%) χ 2 -value df P-value Anemic Freq (%) Not anemic Freq (%) χ 2 -value df P-value Control 171 (51.2) 231 (48.8) 0.079 1 0.30 164 (61.4) 238 (44.1) 21.5 1 0.00 Intervention 163 (48.8) 242 (51.2) 103 (38.6) 302 (55.9) 24 Objective 3: Anemia status of children aged below 5 years in the control and intervention sites at baseline and end-line of the survey

25. Effects of CLTS on aneamia Baseline Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 25

26. Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities 26

27. Group Baseline survey End-line survey With Malntr Freq (%) No Malntr Freq (%) χ 2 -value df P-value With Malntr Freq (%) No Malntr Freq (%) χ 2 -value df P-value Anemic 185 (52.3) 149 (32.9) 30.7 1 0.000 162 (51.6) 105 (21.3) 79.5 1 0.000 Not anemic 169 (47.7) 304 (67.1) 152 (48.4) 388 (78.7) 27 Cross tabulation ( Chi 2 Test) between nutritional status and anemia of children aged < 5 years at baseline and end-line survey

28. 28 Objective 4. Latrine ownership- Bivariate analysis

29. Objective 4 contd..: Latrine ownership- Multivariate analysis (Logistic regression) For multivariate analysis, all variables were included in a stepwise backward logistic regression 29 Characteristics AOR (95% CI) p value Arm CLTS Non CLTS   1 (Reference) 0.29 (0.16-0.53)     0.00 * Land ownership No Yes   1 (Reference) 1.99 (1.27-3.10)     0.00 * Characteristics AOR (95% CI) p value Type of housing Permanent Semi-permanent Temporary   1 (Reference) 0.41 (0.20-0.83) 0.36 (0.15-0.88)     0.01 * 0.02 * Heard of CLTS No Yes   1 (Reference) 2.24 (1.31-3.82) 0.00 * Participated in CLTS No Yes   1 (Reference) 5.49 (3.22-9.35) 0.00 * Received CLTS material No Yes   1 (Reference) 0.16 (0.07-0.34) 0.00*

30. Objective 4 contd … Latrine ownership – Explaination of the 2 tables above Bivariate analysis showed that land ownership and having permanent house structures were all positively associated with latrine ownership (p<0.05) Multivariate analysis showed that CLTS implementation, having a male household head, land ownership and having permanent house structures were all positively associated with latrine ownership p<0.05 . Households in CLTS implementation site were 71% more likely to own a latrine as compared to those in the non-CLTS site (AOR=.29,95% CI:16-.53, P<.001) Households that reported to have heard about CLTS were about 2 times more likely to own a latrine than those who had no knowledge of CLTS. Those that participated in CLTS were five times more likely to own a latrine as compared to non-participants. 30

31. Objective 5.Socio-cultural barriers, level of awareness and practices towards CLTS among household members a) Barriers to CLTS Distance Inadequate medicine Financial constrains Cultural myths Inadequate water sources 31

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35. b) Level of awareness tf CLTS 35 Characteristic n (%) P value CLTS Non CLTS Heard of CLTS No Yes   83 (21.0) 309 (78.0)   80 (19.7) 325 (80.0) 0.344 Participated in CLTS No Yes   145 (36.6) 250 (63.1)   330 (81.3) 76 (18.7) 0.000 Received CLTS material No Yes   116 (29.3) 280 (70.7)   400 (98.5) 6 (1.5) 0.000

36. Awareness of CLTS contd …… 36 Health workers and community health volunteers (CHVs) seemed to be the main advocates of CLTS CHVs seemed to spread the information more than health workers, covering even non CLTS villages.

37. c) Practices of CLTS Despite more availability of handwashing facilities in CLTS implementing sites, the critical handwashing times known to residents varied between the two groups.

38. Discussion Objective 1: Effects of CLTS on Nutrition status of children below 5 years The result implied that CLTS implementation had effects of improving nutritional status of children in the intervention site compared to the control site. (42.72% reduced to 29.38%) Several studies with similar findings CLTS reduce diarrhea, environmental enteropathy and helminthes (Mara, 2017; Mshida et al. , 2018; Gizaw and Worku, 2019) Objective 2: Episodes of diarrhea in the last 6 months among children aged below 5 years. The proportion of Children <5 years with diarrhea in control and intervention groups at based were not statistically different ( p=0.079).At end line survey the proportion of children with diarrhea in the control group was significantly higher than the intervention group( 198(49.2%) vs. 109(26.9%). The result from present study is in line with the previous literature on CLTs in Kenya the study revealed that there was a significant difference in the prevalence of diarrheal diseases between open defecation (OD) and open defecation free (ODF) sub-counties( Njuguna , 2016). 38

39. Discussion contd …. Objective 3: Effects of CLTS on anaemia among children below 5 years At end-line survey, this study indicated that, the proportion of children with anaemia was significantly ( χ 2 = 21.5, df = 1; p-value = 0.00) higher in the control site compared to the intervention site. Children who lack access to proper sanitation are at a higher risk of developing anemia compared to those living in a sanitary environment. ( Coffey, Geruso and Spears, 2018; Kothari et al. , 2019; Mwatsahu, 2021) Malnourished children are more likely to be anemic regardless of the group both at baseline and end line survey 39

40. Discussion contd … Objective 4: Latrine Ownership CLTS implementation ,CLTS knowledge and higher socio-economic status increases the probability of owning a toilet In Ethiopia which found the prevalence of latrine coverage was 79.4% in CLTS villages compared to 59.1% in non-CLTS villages (Megersa and Benti, 2020). Objective 5 Socio-cultural barriers, level of awareness and practices towards CLTS household members in both the intervention site and the control sites. Distance, inadequate medicine , financial constrains ,cultural myths and inadequate water sources were barriers to CLTS implementation. In the current study respondents in CLTS intervention site were more aware and practiced hygiene and Sanitation than those living in the control sites.( awareness and practices). This findings are in line with a study conducted in Zambia which proved that acquaintance of communities to CLTS triggering processes heightened knowledge on hygiene and sanitation (Lawrence et al. , 2016) 40

41. Implications for CLTS The primary actors tasked with overseeing implementation of CLTS, county government staff can significantly influence its success. However, the substantial responsibility they hold requires additional capacity strengthening, external support, and mechanisms for ensuring consistent and effective coordination between county government staff and the NGOs. This research aims to not only advance knowledge of the local and national CLTS context in Kenya, but also highlight the need for policies and programs that support inter-sector coordination and allow governments to progressively build their implementation capacity at the local scale. 41 Source: WHO/UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities

42. Conclusion CLTS reduced the proportion of malnourished children from 42.72% to 29.4% consequently the proportion of malnourished children reduced significantly by 31%. Implementation of CLTS reduced the proportion diarrhea in children from 52.6% to 26.9% and thus reducing the proportion of diarrhea in children significantly by 48.8%. CLTS reduced the proportion of anemic children from 48.8% to 38.6% therefore reducing the proportion of anemic children significantly by 36.8%. CLTS implementation, having a male household head , owning a land and having a permanent house structure significantly predicted latrine ownership. Distance, inadequate medicine, financial constrains, cultural myths and inadequate water sources were barriers to CLTS. Community health volunteers and community health workers spread more information on CLTS both in the control and intervention groups. 42

43. Key Recommendations Scaling of CLTS will contribute to reduction of aneamia ,diarrhea Survival to age 5 50m out of sch ool Low completion and learning outcomes Education High stunting (32% under 5 years; 30%-stunting % for Kwale) 200,000 maternal deaths annually >700,000 deaths due to TB and HIV/AIDS annually Health and nutrition 43 H igh fertility rates compared to the rest of the world (4.8 compared to 2.4) High fertility 7 1% of the poorest not covered by any social protection program 18 countries facing situations of FCV Social protection L arge within country disparities (geographical, by gender, by wealth quintile) in human capital Others 43

44. Acknowledgement JKUAT for offering me a chance to pursue my course. Support and guidance from my supervisors Kwale County (Department of Health Services) Community members from Chengoni village unit, Samburu- Chengoni ward, Kinango Sub-County, Kwale County 44

45. Thank you 45