LATRINE USE AND ASSOCIATED FACTORS AMONG

RURAL COMMUNITY MEMBERS IN SAMBURU EAST

SUB-COUNTY, SAMBURU COUNTY, KENYA

RACHEAL WANJIKU WAITHAKA (BSC. ENVIRONMENTAL HEALTH)

P57/CTY/PT/23712/2011

A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE

REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF

PUBLIC HEALTH (MONITORING AND EVALUATION) IN THE SCHOOL

OF PUBLIC HEALTH OF KENYATTA UNIVERSITY

FEBRUARY 2015
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DECLARATION

This thesis is my original work and has not been presented for a degree in any other

University.

Signature …………………………… Date………………………

Name Racheal Wanjiku Waithaka

P57/CTY/PT/23712/2011

Supervisors:

This thesis has been submitted for review with our approval as University

Supervisors.

1. Signature

.…………………………………… Date …………………….

Dr. Justus O.S. Osero

Department of Community Health

2. Signature

.…………………………………… Date …………………….

Dr. Peterson N. Warutere

Department of Environmental Health

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DEDICATION STATEMENT

To the one who taught me the value of hard work and the fear of God, the one in

whose eyes I only see strength, patience, courage and unconditional love; to my

beloved Mother, Ziborah Wairimu Waithaka.

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ACKNOWLEDGEMENT

I am grateful to my supervisors, Dr. Justus O.S. Osero, Dr. Peterson Warutere and Dr.

Daniel Akunga for their tremendous support and advice given throughout the study

process. I also wish to thank my sister, Dr. Eunice Njambi for all the support and

advice given during the study. To the research assistants, the community members

and all the key informants who participated in the study in Samburu East Sub County,

I say a big thank you.

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TABLE OF CONTENTS

DECLARATION.......................................................................................................... I
DEDICATION STATEMENT .................................................................................. II
ACKNOWLEDGEMENT ........................................................................................ III
LIST OF TABLES ................................................................................................... VII
LIST OF FIGURES ............................................................................................... VIII
ABBREVIATION AND ACRONYMS ................................................................... IX
DEFINITION OF TERMS......................................................................................... X
ABSTRACT ............................................................................................................... XI
CHAPTER ONE: INTRODUCTION ........................................................................ 1
1.1 BACKGROUND TO THE STUDY ............................................................................. 1
1.2 STATEMENT OF THE PROBLEM ............................................................................. 3
1.3 JUSTIFICATION .................................................................................................... 4
1.4 OBJECTIVES ........................................................................................................ 5
1.4.1 Main Objective ........................................................................................... 5
1.4.2 Specific Objectives ..................................................................................... 5
1.5 RESEARCH QUESTIONS ....................................................................................... 5
1.6 HYPOTHESIS........................................................................................................ 5
1.7 DELIMITATION AND LIMITATION ......................................................................... 6
1.7.1 Delimitation ............................................................................................... 6
1.7.2 Limitations ................................................................................................. 6
1.8 CONCEPTUAL FRAMEWORK ................................................................................. 7
CHAPTER TWO: LITERATURE REVIEW .......................................................... 9
2.1 INTRODUCTION ................................................................................................... 9
2.2 IMPROVED LATRINE USE ...................................................................................... 9
2.3 SANITATION POLICY CONTEXT .......................................................................... 12
2.4 LATRINE USE KNOWLEDGE, ATTITUDE AND HYGIENE PRACTICES ...................... 16
2.5 FACTORS PROMOTING LATRINE USE .................................................................. 18
2.6 FACTORS HINDERING LATRINE USE ................................................................... 19
CHAPTER THREE: MATERIALS AND METHODS ........................................ 21
3.1 INTRODUCTION ................................................................................................. 21
3.2 RESEARCH DESIGN ........................................................................................... 21
3.3 VARIABLES ....................................................................................................... 21
3.3.1 Dependent Variable ................................................................................. 21
3.3.2 Independent Variables ............................................................................. 21
3.4 STUDY LOCATION.............................................................................................. 22
3.5 STUDY POPULATION .......................................................................................... 23
3.6 SAMPLE SIZE AND SAMPLING TECHNIQUES ........................................................ 23
3.6.1 Sample size ............................................................................................... 23
3.6.2 Sampling Techniques ............................................................................... 25
3.7 PRE TESTING ..................................................................................................... 26
3.8 VALIDITY .......................................................................................................... 26
3.9 RELIABILITY ..................................................................................................... 26
3.10 DATA COLLECTION TECHNIQUES ................................................................... 27
3.10.1 Household questionnaire ..................................................................... 27
3.10.2 Observation checklist ........................................................................... 28
3.10.3 Transect walks ...................................................................................... 28
3.10.4 Focus Group Discussion and Key Informant Interview....................... 29
3.10.5 Training of research assistants ............................................................ 30
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3.11 LOGISTICAL AND ETHICAL CONSIDERATIONS ................................................ 30

3.12 DATA ANALYSIS ........................................................................................... 31
CHAPTER FOUR: RESULTS ................................................................................ 32
4.1 INTRODUCTION ................................................................................................. 32
4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ...................... 32
4.2.1 Area of residence ..................................................................................... 32
4.2.2 Gender...................................................................................................... 33
4.2.3 Age of household head ............................................................................. 33
4.2.4 Occupation of the household head ........................................................... 34
4.2.5 Level of education of household head ...................................................... 34
4.2.6 Household average monthly income ........................................................ 34
4.2.7 Household size ......................................................................................... 34
4.3 LATRINE USE FACTORS ...................................................................................... 35
4.3.1 Human waste disposal methods ............................................................... 35
4.3.2 Latrine construction skills........................................................................ 35
4.3.3 Gender responsible for latrine construction and cleaning ...................... 36
4.3.4 Motivation for constructing and using latrines ....................................... 37
4.3.5 Diseases suffered by household members in the past two weeks ............. 38
4.3.6 Promoters of latrine construction and use in the study area ................... 38
4.3.7 Latrine construction financing ................................................................. 39
4.4 KNOWLEDGE AND ATTITUDES ON LATRINE USE ................................................ 40
4.4.1 Knowledge on causes and transmission of diarrhoea ............................. 40
4.4.2 Knowledge on prevention of diarrhoea ................................................... 41
4.4.3 Knowledge on benefits of using latrines .................................................. 41
4.4.4 Latrine use attitudes................................................................................. 42
4.5 LATRINE USE HYGIENE PRACTICES .................................................................... 44
4.6 SOCIO-DEMOGRAPHIC VARIABLES ASSOCIATED WITH LATRINE USE .................. 45
4.7 KNOWLEDGE AND ATTITUDES ASSOCIATED WITH LATRINE USE ........................ 46
4.7.1 Knowledge on causes of diarrhoea associated with latrine use .............. 46
4.7.2 Knowledge on prevention of diarrhoea associated with latrine use........ 47
4.7.3 Knowledge on latrine benefits associated with latrine use ...................... 48
4.8 HYGIENE PRACTICES ASSOCIATED WITH LATRINE USE ...................................... 49
4.9 FACTORS ASSOCIATED WITH PROMOTING LATRINE USE..................................... 49
4.9.1 Living in close proximity to market centres ............................................. 49
4.9.2 Clearly defined gender roles .................................................................... 50
4.9.3 Provision of subsidies in latrine construction ......................................... 51
4.9.4 Motivation for latrine construction and use ............................................ 51
4.10 FACTORS ASSOCIATED WITH HINDERING LATRINE USE .................................. 52
4.10.1 Cultural beliefs, taboos and traditions ................................................ 52
4.10.2 Perceived poverty levels ...................................................................... 52
4.10.3 High illiteracy levels ............................................................................ 52
4.10.4 Lack of latrine construction skills ........................................................ 54
4.10.5 Low government involvement in promoting latrine use ....................... 54
4.10.6 Low involvement of men in latrine related matters ............................. 54
4.10.7 Low self-initiation of latrine construction ........................................... 54
CHAPTER FIVE: DISCUSSION, CONCLUSION AND
RECOMMENDATIONS........................................................................................... 55
5.1 INTRODUCTION ................................................................................................. 55
5.2 DISCUSSION ...................................................................................................... 55
5.2.1 Socio-demographic characteristics of the study population .................... 55
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5.2.2 Knowledge and attitudes on latrine use ................................................... 58

5.2.3 Latrine use hygiene practices .................................................................. 59
5.2.4 Factors that promoted latrine use in the study area ................................ 59
5.2.5 Factors that hindered latrine use in the study area ................................. 62
5.3 CONCLUSION..................................................................................................... 68
5.4 RECOMMENDATIONS ......................................................................................... 69
5.5 FURTHER RESEARCH ......................................................................................... 70
REFERENCES ........................................................................................................... 71
APPENDICES ............................................................................................................ 75
APPENDIX 1: JMP METHOD OF CATEGORIZING TYPES OF LATRINE FACILITIES........ 75
APPENDIX 2: INFORMED CONSENT FORM.................................................................. 76
APPENDIX 3: HOUSEHOLD QUESTIONNAIRE .............................................................. 77
APPENDIX 4: FOCUSED GROUP DISCUSSION AND KEY INFORMANT GUIDE ............... 84
APPENDIX 5: KENYATTA UNIVERSITY ETHICS REVIEW COMMITTEE APPROVAL ...... 86
APPENDIX 6: NATIONAL COMMISSION OF SCIENCE, TECHNOLOGY AND INNOVATION
RESEARCH AUTHORIZATION ..................................................................................... 88
APPENDIX 7: NATIONAL COMMISSION OF SCIENCE, TECHNOLOGY AND INNOVATION
RESEARCH CLEARANCE PERMIT ............................................................................... 89
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LIST OF TABLES
Table 3.1: Study sample size per location ................................................................... 24
Table 4.1: Socio-demographic characteristics of the study respondents ..................... 33
Table 4.2: Knowledge on causes and transmission of diarrhoea ................................. 40
Table 4.3: Knowledge on prevention of diarrhoea ...................................................... 41
Table 4.4: Knowledge on importance of latrines ......................................................... 41
Table 4.5: Latrine use hygiene practices at the household level.................................. 45
Table 4.6: Socio-demographic variables associated with latrine use .......................... 46
Table 4.7: Knowledge on causes of diarrhoea associated with latrine use .................. 47
Table 4.8: Knowledge on prevention of diarrhoea associated with latrine use ........... 48
Table 4.9: Knowledge on latrine benefits associated with latrine use ......................... 48
Table 4.10: Hygiene practices associated with latrine use .......................................... 49
Table 4.11: Factors associated with promoting latrine use .......................................... 50
Table 4.12: Diseases suffered in the past two weeks associated with latrine use ........ 52
Table 4.13: Factors associated with hindering latrine use ........................................... 53
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LIST OF FIGURES
Figure 1.1 Conceptual Framework for the study ........................................................... 8
Figure 3.1: Map of the study area ................................................................................ 22
Figure 4.1: Human waste disposal methods ................................................................ 35
Figure 4.2: Latrine construction skills ......................................................................... 36
Figure 4.3: Gender responsible for constructing latrines ............................................. 36
Figure 4.4: Motivation for constructing and using latrines ......................................... 37
Figure 4.5: Diseases suffered by household members in the past 2 weeks ................. 38
Figure 4.6: Promoters of latrine construction and use ................................................. 39
Figure 4.7: Financing for latrine construction ............................................................. 39
Figure 4.8: Obstacles to latrine use .............................................................................. 42
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ABBREVIATION AND ACRONYMS

AfricaSan African Conference on Sanitation and Hygiene

AIDS Acquired Immuno Deficiency Syndrome

ASAL Arid and Semi-Arid Land

DPHO District Public Health Officer

ESH Environmental Sanitation and Hygiene

FGD Focused Group Discussions

GoK Government of Kenya

HIV Human Immuno Deficiency Virus

JMP Joint Monitoring Programme

KDHS Kenya Demographic and Health Survey

KII Key Informant Interviews

MDG Millennium Development Goals

MoH Ministry of Health

MoPHS Ministry of Public Health and Sanitation

NGOs Non-Governmental Organizations

ODF Open Defecation Free

SMEs Subject Matter Experts

SPSS Statistical Package for Social Sciences

TB Tuberculosis

UN United Nations

UNDP United Nations Development Programme

UNICEF United Nations Children’s Fund

VIP Ventilated Improved Pit

WHO World Health Organization

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DEFINITION OF TERMS

In order to avoid ambiguity, the following terms were operationally defined:

Sanitation: The provision of facilities for the safe disposal of human faeces and

urine.

Open defecation: Disposal of human faeces in fields, forests, bushes, bodies of water

or other open spaces.

Latrine: Facilities used for the safe disposal of human faeces and urine.

Latrine use: Use of an improved latrine facility for the safe disposal of human waste

(feces and urine).

Latrine Coverage: Proportion of households having ownership of an improved

latrine facility.

Improved latrines: Facilities that ensure hygienic separation of human excreta from

human contact. The different categories of improved latrine facilities are provided in

Appendix 1.

Unimproved latrines: Facilities that do not ensure hygienic separation of human

excreta from human contact. The different categories of unimproved latrine facilities

are provided in Appendix 1.

Shared latrines: Sanitation facilities of an otherwise acceptable type shared between

two or more households. Shared facilities include public toilets.

Hygiene: The practice of keeping oneself and the surrounding environment clean.
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ABSTRACT
Lack of latrines remain a widespread health and environmental hazard in many
developing countries. Globally, 2.5 billion people do not use improved latrine
facilities and in Kenya, over five million people are forced to resort to open
defecation due to lack of latrines resulting in the prevalence of sanitation related
diseases such as diarrhoea. The study aimed at determining latrine use and associated
factors among the rural community members in Samburu East Sub-County, Samburu
County, Kenya. A community based cross sectional study design was utilized for the
study. Samburu East Sub-County was purposively selected based on its low latrine
coverage while simple random sampling was used to select Nairimirimo Location
which was the study area forming the sampling frame. All the four Sub-Locations
within the study Location were included in the study with the households forming the
sampling units. Systematic random sampling of households was conducted using a
household register to select the households to be included in the study with a pre-
defined skipping pattern of every sixth household being utilized in each Sub-Location.
Quantitative data was collected from 210 community members who were interviewed
using a structured household questionnaire which also included an observation
checklist. Transect walk within the study area was also conducted to make key latrine
use observations. Qualitative data was collected through Focused Group Discussions
and Key Informant Interviews to complement the household survey findings. All field
questionnaires were first checked for completeness, coded, entered into SPSS and
cleaned before data analysis. Descriptive findings are presented as numerical
summaries, tables and charts while inferential statistics made use of Chi-Square and
Fisher’s Exact tests to measure association between the dependent and independent
variables with p values of less or equal to 0.05 being considered statistically
significant. The study findings indicated that latrine use was higher among households
living near market centres (p=0.001), those who had either primary or secondary level
of education (p=0.001), among the low income earners (p=0.033) and also among the
male headed households (p=0.040). Latrine use was however observed to be lowest
among livestock keepers (p=0.001). Further, the study found out that the main factors
hindering latrine use in the study area were: high (88.1%) illiteracy rates (p=0.001),
low (6%) involvement of men (p=0.001) in latrine construction, low (27%)
involvement of the government (p=0.002) in promoting latrine use, cultural beliefs,
taboos and traditions (p=0.002), lack of latrine construction skills (p=0.022), high
(84.8%) poverty levels (p=0.033) and low (17%) self-initiation of latrine construction
(p=0.043). The study concludes that all efforts geared towards up scaling latrine use
in the study area must tackle all the underlying barriers. With one year to the MDG
deadline, concerted efforts are now required to persuade all the stakeholders, National
and County governments to improve latrine use in Samburu East Sub-County in order
to reduce the apparent latrine use disparities for the attainment of the Millennium
Development Goals (MDGs) and the government of Kenya national sanitation targets.
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CHAPTER ONE: INTRODUCTION

This chapter outlines the study background, problem statement, justification,

objectives, research questions, hypothesis, delimitation, limitation and the conceptual

framework.

1.1 Background to the study

Sanitation is a United Nations declared human right and without access to it, many

communities are left vulnerable to impacts on health, dignity, negative economic and

education effects (WHO, 2012a). Lack of latrines mostly affects the poor, rural and

marginalized communities as majority (71%) of those who do not use improved

latrines live in rural areas where 90% of all open defecation takes place. The global

health burden associated with these conditions is staggering, with an estimated 4,000–

6,000 children dying each day from diseases associated with lack of access to

sanitation (WSSCC, 2004). Despite these realities, progress towards meeting the

sanitation Millennium Development Goal (MDG) target for all by 2015 is woefully

off track (WHO and UNICEF, 2013).

Globally, 15% of the world’s population do not use improved latrine facilities forcing

over 1 billion people to resort to open defecation. Overall, the global latrine coverage

as at 2011, was estimated to be 64% implying that the world was set to miss the 75%

sanitation MDG target by more than half a billion people if the current trends

continued (WHO and UNICEF, 2013).

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Sub-Saharan Africa remained the farthest behind in its progress towards accelerating

access to improved latrine facilities (UN, 2013). Regional estimates indicated that

only 30% of the population in Sub Saharan Africa used improved latrine facilities and

an estimated 26% practiced open defecation due to lack of latrines (WHO and

UNICEF, 2013).

Kenya is not on track to meet its sanitation MDG targets by 2015 as only 29% of its

population use improved latrine facilities while 14% practice open defecation with

rural areas recording higher (17%) levels of open defecation compared to urban areas

(3%). This implies that over 5 million Kenyans do not use improved latrine facilities

and are therefore forced to resort to open defecation which results in the prevalence of

sanitation related diseases such as diarrhoea (WHO and UNICEF, 2013). If the

current rate (0.75%) of increasing access to sanitation is maintained, it will take

Kenya 100 years to achieve the MDG targets and 133 years to attain universal access

to sanitation. If the country is to meet its MDG and Vision 2030 targets, this rate must

be increased to 5% (WSP, 2014).

Whereas most studies conducted have focused on establishing the latrine coverage

levels, there is a clear gap in the investigation of the underlying factors leading to the

low latrine coverage levels especially in marginalized areas such as Samburu County.

Therefore this study set out to determine the latrine use and associated factors among

the rural community members of Samburu East Sub-County, Samburu County,

Kenya.
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1.2 Statement of the problem

The lack of improved latrine use in Samburu East Sub-County continues to be a

widespread health and environmental hazard. Latrine coverage in Samburu County is

generally low with the proportion of the population using improved latrine facilities

being estimated at 11.7% (WSP, 2014). According to the 2009 census report, majority

(83%) of the population in Samburu East Sub-County practiced open defecation

(GoK, 2010a) due to lack of latrines. In 2011, the County was ranked the third last out

of the 47 counties with the lowest latrine coverage (GoK, 2011a). The Sub-County’s

health records indicate that majority of the top ten diseases affecting the population

were sanitation related and in 2009, the region was adversely affected by a cholera

outbreak that left many sick and others dead (GoK, 2012a). Overall, 42% of the

children in the County are stunted and the County loses 268 million Kenya Shillings

each year due to poor sanitation (WSP, 2014).

The promotion of improved latrine use coupled with the requisite knowledge, attitudes

and practices has not received significant attention from researchers, the National and

County Governments, programme designers, law enforcers and policy-makers. Latrine

coverage levels both nationally and globally are well studied and documented in the

National census, Kenya Demographic and Health Surveys and the WHO and UNICEF

Joint Monitoring Programme reports. Whereas these studies have focused on

ascertaining the latrine coverage levels, there is limited information on latrine use and

associated factors that are attributed to the low latrine coverage levels among

marginalized pastoral communities such as Samburu County. This study therefore set

out to determine latrine use and associated factors in Samburu East Sub-County,

Samburu County, Kenya.

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1.3 Justification

The world committed itself to halve the proportion of people without access to

sanitation facilities by the year 2015; however this remains a pipe dream for many

countries including Kenya which is one of the countries in Africa that is not on track

to achieve the MDG goals on Sanitation (WHO and UNICEF, 2013).

The sanitation status has been declining in Kenya. With a population of more than 38

million people, Kenya faces enormous challenges in providing sustainable access to

sanitation for its fast growing population. A significant portion of Kenya’s disease

burden is caused by inadequate sanitation and poor personal hygiene practices which

results in the prevalence of sanitation related diseases such as diarrhoea (UNDP,

2009). Samburu East Sub-County was ranked the third last out of the 47 counties

with the lowest latrine coverage (GoK, 2011a) with latrine coverage being lowest in

Wamba Division (19%) compared to Waso (21%) Division (GoK, 2012a). In

addition, majority of the top ten diseases affecting the Sub County’s population were

sanitation related (GoK, 2012a).

Increasing use of improved latrine facilities will make the realization of broader

health, social and wider development outcomes both likely and sustainable (WHO,

2012a). Despite its importance, achieving real gains in increasing latrine use has been

challenging. There is need to understand and document the underlying factors

associated with the low improved latrines use in Samburu East Sub-County in order to

accelerate progress towards attainment of sanitation MDG targets in this marginalized

region.
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1.4 Objectives

1.4.1 Main Objective

To determine latrine use and associated factors among the rural community members

in Samburu East Sub-County, Samburu County, Kenya.

1.4.2 Specific Objectives

1) To establish the knowledge and attitudes on latrine use among the rural

community members in Samburu East Sub-County, Samburu County, Kenya.

2) To establish latrine hygiene practices among latrine users in Samburu East Sub-

County, Samburu County, Kenya.

3) To establish the factors that promoted or hindered latrine use among the rural

community members in Samburu East Sub-County, Samburu County, Kenya.

1.5 Research Questions

1) What knowledge and attitudes on latrine use existed among the rural community

members in Samburu East Sub-County, Samburu County, Kenya?

2) What latrine hygiene practices existed among the latrine users in Samburu East

Sub-County, Samburu County, Kenya?

3) What factors promoted or hindered latrine use among the rural community

members in Samburu East Sub-County, Samburu County, Kenya?

1.6 Hypothesis

The study hypothesized that there were no factors promoting nor hindering latrine use

in Samburu East Sub-County, Samburu County, Kenya.

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1.7 Delimitation and limitation

1.7.1 Delimitation

1) The study only focused on determining latrine use and associated factors

among the rural community members in Samburu East Sub-County, Samburu

County, Kenya as outlined in the study objectives and research questions.

2) The study was limited to the rural community members of Samburu East Sub-

County.

1.7.2 Limitations

1) Samburu East Sub-County is very vast and prone to resource related conflicts.

2) The pastoralist nature of the community hindered the availability of

respondents in some areas. Households that lacked respondents had to be

skipped and alternative ones that met the inclusion criteria were sampled as

replacements.

3) The principal investigator was not a resident of the study area and therefore

language posed a barrier hence local community health workers were used in

translation to bridge this gap.

4) Heavy rains hampered data collection in Lmarmaroi Sub Location, data

collection had to be rescheduled after the rains subsided.

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1.8 Conceptual framework

The Health Belief Model is a psychological model that attempts to explain and predict

health behaviors by focusing on the attitudes and beliefs of individuals. (FHI, 1996).

The model is often used to explore a variety of long and short term health behaviors

such as use of improved latrine facilities.

The model is based on the understanding that a person will take a health-related action

(i.e., use improved latrines) if that person: feels that a negative health condition (i.e.,

diarrhoea) can be avoided, has a positive expectation that by taking a recommended

action, he/she will avoid a negative health condition (i.e., using improved latrines will

be effective at preventing diarrhoea) and believes that he/she can successfully take a

recommended health action (i.e., he/she can use improved latrines comfortably and

with confidence).

The conceptual framework that was adapted and modified for the study is provided as

figure 1.1 below.

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Independent Variables
Latrine use and associated factors

Factors that promote Knowledge, attitudes and Factors that hinder latrine
latrine use practices use
 High income levels  Knowledge on  Lack of latrine
 Suitable hydro- importance of construction skills
geological conditions latrines  Lack of latrine
 Education  Knowledge on construction materials
 Latrine sanctions/law
causes and  Lack of support from
enforcement
 Possession of latrine prevention of local leadership and
construction skills diarrhoea key policy makers
 Availability of latrine  Attitudes on latrine  Poverty
construction materials use  Illiteracy
 Strong social support  Hygiene practices  Socio-cultural taboos
related to latrine use  Inadequate financing
for the sanitation
sector

Dependent Variable

Latrine Use
Defined as the use of an improved latrine facility for the safe disposal of human waste (faeces and urine)

Figure 1.1 Conceptual Framework for the study

Adapted and modified for the study from: Family Health International, 1996.
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CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

This chapter documents literature related to the study and is provided under various

thematic headings namely: improved latrine use, sanitation policy context, latrine use

knowledge, attitude and hygiene practices and factors that promoted or hindered

latrine use.

2.2 Improved latrine use

The continued neglect of the sanitation sector at all levels has been worrying (Water

Aid, 2008). Overall, 80% of countries recognized right to water compared to just over

50% who recognized right to sanitation (WHO, 2012a). Until 2010, the United

Nations (UN) had not recognized access to safe sanitation as a basic human right

(WHO, 2012b) and therefore launched an advocacy initiative dubbed the “Sanitation

Drive to 2015” in order to accelerate progress towards attainment of universal latrine

coverage. Despite the intensive advocacy and lobby initiatives to raise the sanitation

profile globally, the sanitation sector remains underfunded and a key challenge in

most developing countries (WSP, 2012).

The United Nations MDG target 7c aims at halving the proportion of people without

sustainable access to safe drinking water and basic sanitation by the year 2015. In this

commitment, a target for sanitation of 75 percent was set to be reached by 2015.

However, it is estimated that as at the end of 2011, the world had only attained 64%

latrine coverage. Globally, an estimated 2.5 billion people lack access to improved

sanitation which is more than 35% of the world's population. Without immediate

acceleration in progress, the world will not achieve the MDG sanitation target if the
 10

current trends persist. Overall, (71%) of those who do not use improved latrines live

in the rural areas where 90% of all open defecation takes place (WHO and UNICEF,

2013). Slight progress has been made especially in Sub Saharan Africa where

improved latrine use level stands at 30%. Despite the regional progress made,

expansion of latrine use is uneven and marked with disparities.

Kenya is equally not on track to attain its MDG’s targets for sanitation; only 29%

have access to an improved latrine facility with over 5 million Kenyan’s practicing

open defecation due to lack of latrines. Poor sanitation is expensive; Kenya loses an

estimated KES 27 Billion (365 million USD) each year, which is 1% of national GDP,

due to poor sanitation. Open defecation itself costs Kenya US$88 million per year.

(WSP, 2012). A county-wide benchmarking report showed that counties are losing

millions of shillings due to poor sanitation yet eliminating open defecation would

require much less money in enabling households to build and use latrines (WSP,

2014). Inadequate sanitation continues to strain the health care system with the

economic burden of poor sanitation falling heavily on the poorest (WHO, 2008) who

constitute nearly half of all Kenyans.

Accelerating improved latrine use is both an economic and health gain (WHO, 2004).

By meeting the sanitation MDG target, US$ 60 billion annually will be earned with

90% of these economic benefits being attributed to the role of sanitation alone, with

Sub Saharan Africa standing to benefit a great deal; universal improved latrine use is

expected to triple these benefits (WHO, 2012b); Reaching the sanitation MDG target

will also improve health of workers by adding 3.2 billion annual working days

worldwide while universal sanitation level would multiply this benefit up to four
 11

times (UN University, 2010). Poor sanitation causes diarrhoea, a highly preventable

disease which kills 1.5 million children annually, more than malaria, measles and

AIDS combined and is the second leading cause of death among children under the

age of five years (UNICEF and WHO, 2009). Diarrhoeal diseases is a direct cause of

11% of under-five mortality globally with developing countries especially Sub

Saharan Africa bearing the most consequences; the major contributing factor being

open defecation practiced by 1.1 billion people (UNICEF, 2012).

Evidence from various cross-country studies indicates that sanitation remains one of

the strongest determinants of child survival, its role being more superior to that played

by water. Improved sanitation confers up to 37% reduction in childhood diarrhoea

compared to 21% reduction through improved water supply (Bartram et al., 2007).

Esrey et al, (2001) reports similar findings of 35-40% reduction in diarrhoeal diseases

and a further reduction by half of childhood mortality through improved sanitation.

Graham (2001) reports that partial improved latrine use (Possibly >50%) contributes

to reduction in diarrhoeal diseases benefiting an entire community due to safer

community environments. Further evidence indicates that the duration of latrine

ownership has an impact on the occurrence of childhood diarrhoea (Anteneh, &

Kumie, 2010). Providing appropriate facilities for defecation saves time, reduces

health costs, increases return on education investment and protects investments in

improved water supply among many more benefits. Therefore the long neglected

sanitation sector is a proven investment with high economic returns of improving

health (UN, 2008).

 12

Increasing access to improved latrines is not only possible, it is essential for nations to

prosper. Although Governments and other partners continue to make commitments to

increase improved latrine use as well as funding for the sector, the efforts are not

adequate to address the current improved latrine use disparities. Without concerted

action, the lack of sanitation will continue to impact the lives of millions of people

and impede progress on development. With a focus now on attaining MDGs, more

concerted efforts are required to improve the poor performance of the sanitation

targets.

Whereas most studies conducted have focused on establishing the latrine coverage

levels, there is a clear gap in the investigation of the underlying factors leading to the

low latrine coverage levels especially in marginalized areas such as Samburu County.

Therefore this study set out to determine the latrine use and associated factors among

the rural community members of Samburu East Sub-County, Samburu County,

Kenya.

2.3 Sanitation policy context

At the Millennium Summit in September 2000, world leaders agreed on a bold vision

for the future through the Millennium Declaration. The Millennium Development

Goals (MDGs) were a pledge to uphold the principles of human dignity, equality and

equity, and free the world from extreme poverty. The MDGs, with eight goals and a

set of measurable time bound targets with a deadline of 2015, established a blueprint

for tackling the most pressing development challenges of our time. Target 7c of the
 13

MDGs aims to “Halve, by 2015, the proportion of the population without sustainable

access to safe drinking water and basic sanitation” (UN, 2013).

Recognizing that Africa was not on track to attain the sanitation MDG targets,

Ministers and Heads of Delegation responsible for sanitation from 32 African

countries including Kenya came together in 2008 at the Second African Conference

on Sanitation and Hygiene (AfricaSan) and signed the eThekwini Declaration with

firm resolutions to: establish, review, update and adopt national sanitation and

hygiene policies, place sanitation and hygiene at the top of the development agenda in

Africa, improve coordination and accountability for sanitation, establish specific

public sector budgets for sanitation with a minimum of 0.5% of GDP being allocated

for sanitation and hygiene, promote use of effective and sustainable hygiene and

sanitation approaches among others (AMCOW, 2008).

The right to sanitation stipulates that every person should have access to affordable

sanitation facilities of acceptable quality for personal use as recognized by the United

Nations. This is a right that Kenya as a country has entrenched in its constitution’s

bill of rights and has committed to deliver to its citizens through its National

Sanitation Policies. The Social strategy pillar of Kenya’s Vision 2030 aspires to make

all social development services including sanitation equitable and accessible to all

Kenyans. The goal for the sanitation sector is such that all Kenyan citizens will have

access to affordable sanitation facilities by the year 2030 therefore making access to

improved sanitation services both available and accessible to all (GoK, 2007a).
 14

The National Environmental Sanitation and Hygiene Policy provides direction on

planning and implementing sanitation objectives in Kenya. The Policy envisions to

create and enhance an enabling environment in which all Kenyans will be motivated

to improve their hygiene behaviour and environmental sanitation. As a contribution to

Kenya attaining the Millennium Development Goals, the policy envisaged that by

2015: All households will be educated and made aware of the importance and need

for improved Environmental Sanitation and Hygiene (ESH) practices for improved

health resulting in positive changes in behaviour;. Every school, institution,

household, market and other public place will have access to, and make use of,

hygienic, affordable, functional, and sustainable toilet and hand washing facilities; All

premises, dwellings and their immediate surroundings will be clean and free from

waste and unpleasant odours and will have adequate drainage and that the burden of

environmental sanitation and hygiene related diseases will be drastically reduced.

This policy was developed to make contributions to the dignity, health, welfare, social

wellbeing and general prosperity of all Kenyans. The policy recognizes that healthy

and hygienic behavior and practices begin with the individual. The implementation of

the policy is aimed at increasing the demand for sanitation at the household level and

encourage communities to take responsibility for improving the sanitary conditions of

their environment (GoK, 2007b).

As a basic human right, all Kenyans should enjoy a dignified quality of life in a

hygienic and sanitary environment and be free from suffering any ill health caused by

poor sanitation. Indeed, the Kenya Health Sector Strategic Plan identifies sanitation as

one of the six essential priority health packages for implementation in the health

sector. The National Health Sector Strategic Plan aims to increase sanitation coverage
 15

from 46% to 66%, identifies the core function of Ministry of Public Health and

Sanitation as “Sanitation Oversight” and provides strategic priority to improve

sanitation in Kenya (GoK, 2008-2012a). The Comprehensive National Health Policy

Framework aims to attain the highest possible standards of health specifically in the

improvement of life expectancy and ill health rate in Kenya (GoK, 2011b).

The Joint Monitoring Report of 2013 identified Kenya as one of the countries in

Africa which was not on track to achieve the MDG goals on Sanitation. With the

renewed and strong government commitment there has been a strong desire to

accelerate progress towards attainment of the MDG targets. However since the

remaining time to attain the MDGs was short and the regular programmatic approach

being considered was not an option, the Ministry of Health embarked on a campaign

mode to achieve an Open Defection Free Kenya. To accelerate progress towards

attainment of sanitation MDG targets in Kenya, the government through the Ministry

of Health launched the ODF Rural Kenya Campaign on 11th May 2011 with an

overall goal of eradicating open defecation in rural Kenya (GoK, 2011c).

The Kenya Health Policy outlines the long term development and management

strategy of health services in Kenya (Gok, 2012-2030) while the Public Health Act

Chapter 242 lays the foundation for all Public Health related Policies in Kenya and

includes provisions for sanitation (GoK, 2012b).

The new Constitution of Kenya of 2010 Chapter 43, Part 2 11b outlines the economic

and social rights of every Kenyan. In this bill of rights, every person including the

minorities and marginalized groups have the right to the highest attainable standard of
 16

health, which includes the right to health care services, accessible, adequate and

reasonable standards of sanitation. Since March 2013, Kenya commenced the

implementation of the new devolved system of government. Sanitation services is

among the key functions devolved to the County governments and therefore all

County governments have been mandated to ensure the provision of adequate

sanitation services to its people.

2.4 Latrine use knowledge, attitude and hygiene practices

Sanitation embodies:-availability, accessibility, quality, and use. Improving sanitation

is not limited to physical-structural aspects but also includes having the correct

knowledge on latrine use, proper use and maintenance of latrine facilities as well as

behaviour change towards more hygienic practices. Kenya has domesticated its MDG

targets for sanitation with an ultimate goal of reducing the incidence of sanitation-

related diseases. These targets are such that by 2015 all households will be made

aware of the importance of improved Environmental Sanitation and Hygiene (ESH)

practices for improved health; 90% of households will have access to hygienic,

affordable and sustainable toilet facilities; and every school will have hygienic toilets

and hand-washing facilities – for girls and boys separately (Gok, 2010b).

Sanitation and hygiene are critical to health, survival, and development. Many

countries are challenged in providing adequate sanitation for their entire populations,

leaving people at risk of water, sanitation, and hygiene related

diseases. Approximately 19,500 Kenyans, including 17,100 children under the age of

five years, die each year from diarrhoea (Gok, 2012c). Diarrhoea prevalence for

children under the age of five years remains at 17% nationally, but disproportionately
 17

affects the poorest people in the population (KDHS, 2010). Diarrhoeal diseases are

the third most prevalent cause of mortality in Kenya resulting in 7% of all deaths in a

year. Diarrhoea is ranked third in most rural public health facilities. According to the

Ministry of Health, approximately 80% of hospital attendance in Kenya is due to

preventable diseases. About 50% of these diseases are sanitation and hygiene related

(GoK, 2011d). Existing evidence suggest that diarrhoea is slightly less common

among children who used improved latrines compared with those who did not (WSP,

2013). Overall, 35% of children in Kenya suffer from moderate to severe stunting.

Childhood stunting, which can affect both educational and long-term productivity

outcomes, has been linked to poor sanitation and hygiene and in particular open

defecation practices (SOWC, 2013).

With over 5.8 million Kenyans still defecating in the open (WHO and UNICEF

2013), the prevalence of diseases such as diarrhoea, amoeba, typhoid and cholera will

continue to persist unless drastic action is taken to raise the knowledge and awareness

levels on latrine use, change attitudes towards use of latrines as well as promote

adoption of appropriate latrine hygiene practices at the household level.

A 1993 WHO meeting of health specialists gave excreta disposal and personal

hygiene practices especially handwashing as the most influential factors in reducing

morbidity and mortality due to diarrhoeal diseases. According to WHO, a 1991

review of 144 studies linking sanitation and water supply with health clearly states

that: “the role of water quality in diarrhoeal disease control is less important than that

of sanitation and hygiene”. Further, WHO repors that, a 1986 study emphasized the

importance of sanitation specifically as compared to stand alone water supply

 18

interventions. Overall, 70% of the studies which looked at sanitation alone, and 75%

of those which considered sanitation and water supply, demonstrated positive health

benefits, compared with 48% of those which considered water supply alone. Further,

research has shown that improved water quality alone can reduce incidences of

childhood diarrhoea by 15-20%, better hygiene through hand-washing reduces it by

35% and safe disposal of children and adults’ faeces leads to reduction of nearly 40%.

A combination of all these three elements reduces incidences of childhood diarrhoea

by up to 95% (WHO, 2008).

According to UNICEF, poor sanitation and hygiene practices have many serious

repercussions. Children – and particularly girls – are denied their right to education

because their schools lack private and decent sanitation facilities. Th poor low wage

earners are less productive due to illness, health systems are overwhelmed and

national economies suffer. Without sanitation and hygiene, sustainable development

is impossible. Improving sanitation and hygiene not only results in good health but

also generates considerable socio-economic benefits in terms of a better living

environment and an expression of care for the dignity of citizens, especially women

and children (UNICEF, 2013).

2.5 Factors promoting latrine use

Ownership of a latrine facility does not guarantee health benefits unless the said

facility is utilized effectively (Anteneh, & Kumie, 2010). However, many factors have

been shown to promote latrine use such as behavioral, demographic, geographic,

climatic and economic (LabSpace-the Open University, n.d.). Studies conducted in

Tanzania and Ethiopia further indicated that socio-demographic and economic factors
 19

significantly promoted use of latrine facilities at the household level (Kema, 2012,

Awoke & Muche 2013).

In addition, supportive supervisory visits to households by health personnel, presence

of school going children, peer pressure, social learning and living in close proximity

to a health institution have also been found to promote latrine use (Anteneh, &

Kumie, 2010). However, controlling for all these factors has shown that stronger

social ties have a greater influence on latrine use (Shakya et al. 2012).

A household’s decision to adopt the use of latrine facilities has little to do with the

prevention of fecal-oral diseases (Jenkins, 2007). Despite the fact that sanitation is

often perceived to be a household matter, the influence of wider community factors

may not be overruled and an in-depth understanding of all factors promoting latrine

use at all levels is valuable (World Bank, 2004).

2.6 Factors hindering latrine use

Improving latrine use guarantees a wide range of benefits to an individual, the

household and community at large. However many barriers exist at National level

including weak national strategies and policies, inadequate financing and low

prioritization of latrines by Governments. At the household level, higher priority has

been accorded to water than latrines as water has direct tangible outcomes compared

to latrines. Poverty and gender inequalities could further explain the disparities in

latrine use among communities with evidence suggesting that women place a higher

value on private latrine facilities than men yet they have the least decision making

power as well as control over household resources (UNDP, 2006).

 20

In other studies, odor and fly problems have also been shown to hinder use of latrines

at the household level (Anteneh, & Kumie, 2010). Globally, the misunderstanding on

the linkage between sanitation and health, institutional and policy shortcomings

limited infrastructure and social taboos further pose additional barriers (UN

University, 2010). In Kenya, the main hindrances to up scaling latrine use have been

reported to be low prioritization of sanitation by policy makers, inadequate funding

for the sanitation sector, adverse hydro-geological conditions, flooding in low lying

areas among others (WSP, 2004).

 21

CHAPTER THREE: MATERIALS AND METHODS

3.1 Introduction

This chapter provides an overview of the materials and methodological details that

were appropriate for the study. The chapter outlines the research design, study

variables, study location, sample size, sampling techniques, pre-testing, validity,

reliability, data collection techniques, logistical and ethical considerations and data

analysis procedures.

3.2 Research Design

A community based cross sectional study design was utilized among the

systematically randomly selected households in the study area. This research design

was used to provide valuable information pertaining to the levels of a particular

attribute of interest (in this case level of latrine use) in a defined population (Samburu

East Sub-County) at a particular point in time.

3.3 Variables

3.3.1 Dependent Variable

The dependent variable for the study was latrine use which was defined as the use of

improved latrine facilities for the safe disposal of human waste (feces and urine).

3.3.2 Independent Variables

1) Factors that promote latrine use such as latrine use knowledge and good hygiene

practices, high income levels, suitable hydro-geological conditions, literacy,

 22

latrine sanctions or law enforcement, possession of latrine construction skills,

access to latrine construction materials, strong social support among others.

2) Factors that hinder latrine use such as lack of latrine use knowledge, poor hygiene

practices, lack of latrine construction skills and materials, poverty, illiteracy,

negative attitudes on latrine use, socio-cultural taboos, inadequate financing for

the sanitation sector, lack of support from local leadership and key policy makers

among others.

3.4 Study location

The study was undertaken in Nairimirimo Location in Wamba Division of Samburu

East Sub-County, Samburu County in Kenya. As indicated in the area map in figure

3.1 below, the study Location had 4 Sub Locations namely: Lmarmaroi, Swari, Raraiti

and Lorok Onyokie each with one main village whose name corresponded to the Sub

Location name. The Sub-County lies on longitude 39.27890 and latitude -3.77864.

Altitude in the Sub-County ranges from 500m to 2,500m above sea level. (GoK 2008-

2012b).

Figure 3.1: Map of the study area

 23

3.5 Study population

The study population consisted of household heads or their representatives and key

informants from the study area of Nairimirimo Location. The Location had a total

population of 5,411 people and 1,218 households based on the 2009 census results

(GoK, 2010a.)

3.6 Sample size and sampling techniques

3.6.1 Sample size

The sample size for the study was determined using the sample size calculation

designed by Fisher et al. (1998) as detailed below:

Where:

n= Sample size

Z= Standard Normal Deviate (1.96) which corresponds to 95% confidence interval

p= Expected prevalence (0.19) Latrine coverage in Wamba Division was 19%

d= Degree of accuracy= 0.05

Therefore:

Since the target population in Nairimirimo Location was less than10,000; a second

formula of Fisher’s et al. was used:

 24

Where:

nf=the desired sample size when the population is less than 10,000

n=the desired sample size calculated using the first formula=236

N=the estimate of the population size=1,218 households.

Therefore:

The above sample size of 198 households was the calculated bare minimal for

statistical significance calculations (representativeness and generalizability). A total

of 210 household questionnaires were therefore collected during the study since any

number above the calculated bare minimal is always preferred. A breakdown of the

administrative units, population, number of households and sample size per Sub

Location is provided in table 3.1 below:

Table 3.1: Study sample size per location

Division Sub Locations Population % Households Name of Village Sample Size

Lmarmaroi 748 192 (16%) Lmarmaroi 33

Swari 1,967 457 (38%) Swari 79
Wamba
Raraiti 995 205 (17%) Raraiti 35
Lorok Onyokie 1,701 364 (30%) Lorok Onyokie 63
Total 4 5,411 1,218 210
 25

3.6.2 Sampling Techniques

Samburu East Sub-County was purposively selected based on latrine coverage

background information available that ranked the sub county as the third last out of

the 47 counties with the lowest latrine coverage. Simple random sampling was used to

select Wamba Division and Nairimirimo Location. The four Sub-Locations

administrative units formed the sampling frame while households were the sampling

units. Within the 1,218 households in the four sub-locations, systematic random

sampling of the 210 households was conducted using a household register which was

obtained from the area chief’s offices indicating all households in the study area; the

household register did not have a specific order of households form the first to the last

one.

Within each Sub-Location, a pre-defined skipping pattern was used to select

households to be sampled for inclusion. This was obtained by taking the total number

of households in each Sub Location divided by the sample size in each Sub Location.

Hence, for every six households, one was sampled for inclusion in the study until the

desired sample size in each Sub-Location was achieved. The study targeted rural adult

household heads or their spouses in the four Sub-Locations of Nairimirimo Location.

The study excluded children aged less than 18 years and visitors as household

representatives. Households without respondents who met the inclusion criteria or

were absent were skipped and alternative households sampled for inclusion using a

similar skip pattern.

 26

3.7 Pre Testing

A pretest of the research instruments was undertaken with an aim of checking the

clarity, consistency and relevance of the questions in relation to the purpose of the

study as well as judge if the questions prompted the kind of responses expected. Ten

percent of the household questionnaires (21) were pre tested and the results of the

pretest were used to correct ambiguous questions, ideas and statements in the data

collection instruments.

3.8 Validity

Validity considerations were made to ensure that the research truly measured that

which it was intended to measure. Content validity was enhanced by consulting

Subject Matter Experts (SMEs) who reviewed the content of the research collection

instruments in line with the study objectives. The use of probability sampling

technique ensured external validity that is generalizability of the results of the study

while pre testing of tools further enhanced validity. Internal validity was strengthened

by limiting the study to residents of Nairimirimo Location.

3.9 Reliability

To ensure that the research instruments used for data collection allowed for

replicability or repeatability of results or observations, all questions were consistently

asked in the local language (Samburu). Definition of operational terms, thorough

training of translators, pre-testing of data collection tools, daily field meetings with

the research assistants and close observation was undertaken by the principal

investigator to further safeguard the reliability of the data collected. Completed

 27

questionnaires were re-checked for completeness and errors were corrected

immediately.

3.10 Data collection techniques

3.10.1 Household questionnaire

A structured household questionnaire was designed to collect quantitative data

relevant to the objectives of the study from a total of 210 study respondents. The

questions in the research instruments were divided into various thematic sections

in line with the study objectives to provide information relevant to the study. All

research instruments were translated into Samburu and then back-translated into

English to ensure precision in the wording of the questions. The research

instruments were subsequently revised to eliminate problems in translation and

language comprehension.

All questions were asked in the local Samburu language; part of the household

questionnaire required the principal investigator to ask questions on various topics

to a respondent (pre-coded and un-coded responses were expected) and other

questions required the principal investigator to make key observations as indicated

in the observation checklist. Informed consent from all respondents was obtained

prior to data collection. The Informed consent form is provided as Appendix 2

while the household questionnaire is provided as Appendix 3.

 28

3.10.2 Observation checklist

Observations, as a method of collecting research data was used during the study

and involved observing latrine use practices and systematically recording the

results of those observations using an observation checklist which was included in

the household questionnaire. The key observations that were made in the study

were guided by the research questions. For each household that was visited during

the study, it was observed whether the household had a latrine or not and the type

of latrine (improved or un-improved). Further, the adoption of good latrine

hygiene practices by latrine users in the study area was observed and

systematically recorded in the observation checklist. This included, the cleanliness

and privacy of the latrine and presence of a hand washing facility near the latrine.

All observations were immediately recorded in the observation check list as they

were made to avoid recall bias.

3.10.3 Transect walks

To complement the other data collection tools, a systematic walk along a defined path

across the study area together with the local people was conducted to explore the

sanitation conditions by observing, asking, listening and looking. Before undertaking

the transect walk, a group of key informants and community members were selected

and briefed on the purpose of the walk. A common path to be followed was agreed

upon to cover the full sanitation variation in the study area. All participants were

sensitized on the key sanitation parameters that were to be observed and recorded.

They included: availability of a latrine, latrine cleanliness, privacy offered by the

latrine and availability of a hand washing device. Local definitions of these

parameters were also agreed upon.

 29

During the walk, discussions were held with the participants on key observations

made which were relevant to the study. The participants were probed further where

observations or discussions were unclear before final observations or notes were

recorded. In addition, selected people met during the walk were

informally interviewed to get their views on the sanitation situation visible at that

spot.

Transect walks through the project area was conducted to observe community

diversity in terms of sanitation, gain an understanding of the sanitation situation of the

study area and latrine use associated factors. The transect walks were also used to

compare reactions and discussions of different Key Informants and community

members involved in the study.

3.10.4 Focus Group Discussion and Key Informant Interview

A Key Informant Interview (KII) and Focus Group Discussion (FGD) guide

(Appendix 4) was designed to collect qualitative data. This guide contained a list of

questions to guide and narrow the discussions to the relevant issues around the

research questions. A total of four Focus Group Discussions (2 for men and 2 for

women) were conducted with a total of 52 participants (24 males and 28 females). In

addition, three Key Informant Interviews targeting the Sub-County Public Health

Officer, an Administrative Official and Swari Health Facility Nurse were conducted.

During the FGDs and KIIs, the principal investigator assisted by two research

assistants took notes based on responses from all participants to enable comparison

and ensure adequacy of information captured during the interviews. The aim of the

FGDs and KIIs was to supplement the quantitative data collected from the households
 30

as well as obtain background information to determine whether or not the situation in

the surveyed areas reflected the general situation within the entire community.

3.10.5 Training of research assistants

Four local community health workers who were literate and residents of the study

area were recruited from each Sub-Location to assist the principal investigator in

interpretation of the study questions and note taking during the data collection

process. The research assistants underwent a training facilitated by the Principal

Investigator regardless of their previous experience in undertaking similar studies.

The training specifically covered: the purpose and objectives of the study, tools and

methods of data collection and general interviewing and note taking techniques.

3.11 Logistical and ethical considerations

The study focused on latrine use and associated factors, a topic not considered to be

very sensitive especially when discussed within the confines of one’s gender or

society. Participation in the study was voluntary, informed consent (Appendix 2) was

obtained prior to data collection, personally identifiable information such as

participant’s names was not collected and maximum confidentiality of information

gathered was assured to all participants throughout the study process. Ethical

clearance was obtained from Kenyatta University Ethics Review Committee

(Appendix 5) while Research Authorization (Appendix 6) and the Research Clearance

Permit (Appendix 7) were obtained from the National Commission of Science,

Technology and Innovation.

 31

3.12 Data Analysis

All field questionnaires were first checked for completeness, coded, entered into

SPSS and cleaned before data analysis. Ten percent of entered data was re-entered to

check the consistency of originally entered data. The descriptive findings for the study

are presented in the form of numerical summaries, tables and charts while inferential

findings made use of Chi-Square and Fisher’s Exact tests to measure association

between the dependent and independent variables with p values of less or equal to

0.05 being considered to be statistically significant.

 32

CHAPTER FOUR: RESULTS

4.1 Introduction

This chapter details the descriptive and inferential findings from the study. The study

set out to determine latrine use and associated factors among the rural community

members in Samburu East Sub-County, Samburu County, Kenya. The specific

objectives for the study were: to establish the knowledge and attitudes on latrine use,

to establish the latrine hygiene practices among the latrine users and to establish the

factors that promoted or hindered latrine use among the rural community members in

Samburu East Sub-County, Samburu County, Kenya.

4.2 Socio-demographic characteristics of the respondents

Overall, a total of 210 study respondents participated in the study. A total of seven

demographic variables were investigated and they included: area of residence, gender,

age, occupation, education, income and household size. Results in Table 4.1 present

the socio-demographic characteristics of the study respondents.

4.2.1 Area of residence

The study was conducted in all the four sub locations of Nairimirimo location. As

presented in Table 4.1, the study found out that majority (64.8%) of the respondents

came from Lmarmaroi, Lorok Onyokie & Raraiti sub locations and only 35.2% came

from Swari sub location.

 33

Table 4.1: Socio-demographic characteristics of the study respondents

Socio Demographic variables (N=210) N %
Area of residence Swari 74 35.2%
Others - Lmarmaroi, Lorok Onyokie & Raraiti 136 64.8%
Gender Male 92 43.8%
Female 118 56.2%
Age 30 to 40 years 86 41.0%
More than 40 Years 124 59.0%
Occupation Livestock Keeping 168 80.0%
Employed or in trading business 42 20.0%
Level of education None 185 88.1%
Primary & Secondary 25 11.9%
Income Less than Ksh. 5,000 178 84.8%
More than Ksh. 5,000 32 15.2%
Household size 1 to 6 people 143 68.1%
7 and more people 67 31.9%

4.2.2 Gender

More female headed households (56.2%) compared to male headed households

participated in the study as presented in Table 4.1. These findings were similar to

observations made during the FGDs where more (28 out of 52) female participants

were present compared to their male counterparts (24 out of 52).

4.2.3 Age of household head

The study found out that slightly more than half (59%) of the household heads were

more than 40 years of age (Table 4.1). Similar observations were made during the

FGDs where most participants were observed to be adults of middle age and above.
 34

4.2.4 Occupation of the household head

As presented in Table 4.1, majority (80%) of the household heads were livestock

keepers compared to those who were engaged in other forms of occupation such as

formal employment or trading business. As reported during the FGDs, most of the

community members in the study area were reported to be livestock keepers who

depended on their livestock as the main source of their livelihood.

4.2.5 Level of education of household head

The study population exhibited high illiteracy levels; as presented in Table 4.1,

majority (88.1%) of the household heads had no formal education. The District Public

Health Officer (DPHO) reported during the Key Informant Interview (KII) that

majority of the study population had low literacy rates.

4.2.6 Household average monthly income

As presented in Table 4.1, majority (84.8%) of the households had an average

monthly income of less than Kenya Shillings 5,000 compared to the others who had a

monthly income of more than Ksh. 5,000. The low income levels were also reported

in all KIIs and FGDs where respondents indicated that the community members in the

study area were generally poor.

4.2.7 Household size

As presented in Table 4.1, the study found out that majority (68.1%) of the

households had a family size of between one and six people compared to others that
 35

had seven or more people. The family sizes depicted in this study were in tandem with

national average family size estimates of 6 persons per household.

4.3 Latrine use factors

4.3.1 Human waste disposal methods

As presented in Figure 4.1 below, the study observed that majority 192 (91.4%) of the

study population practiced open defecation due to lack of latrines. Overall, only 14

(6.7%) of people in the study area were using improved latrines for the safe disposal

of human waste (feces and urine) compared to 196 (93.3%) who were either using un-

improved latrine facilities or were practicing open defecation.

Figure 4.1: Human waste disposal methods (N=210)

4.3.2 Latrine construction skills

Majority 136 (65%) of the respondents reported that they lacked the necessary skills

for constructing latrines as presented in Figure 4.2 below. According to the area

Chief, latrine use has generally been low in the area of study since ancestral times and
 36

therefore the possession of requisite skills for latrine construction was largely a

challenge in the study area.

Figure 4.2: Latrine construction skills (N=210)

4.3.3 Gender responsible for latrine construction and cleaning

Among households who had latrines, all respondents (100%) reported that women

were responsible for cleaning latrines in their household while a majority 198 (94%)

of the respondents reported that women were responsible for constructing latrine

facilities in their community as presented in Figure 4.3.

Figure 4.3: Gender responsible for constructing latrines (N=210)

 37

4.3.4 Motivation for constructing and using latrines

Two main motives were reported for constructing and using latrines as presented in

Figure 4.4 below. The findings indicate that majority 14 (78%) of the respondents

reported that their main motivation for constructing and using latrines was to prevent

diarrhoeal diseases while others 4 (22%) reported that they constructed latrines as a

result of the health education they had received as well as influence from their

neighbors.

Figure 4.4: Motivation for constructing and using latrines (N=18)

Further findings from the FGDs indicated that the community’s motivation for

constructing and using latrines mostly inclined towards the health benefits of

preventing diseases. A female FGD participant clearly elaborated that “when you

defecate in the open, the faeces are carried by rain into our rivers where we all fetch

our drinking water so if any one drinks this water, they can get diarrhoea but if we all

have latrines and we do not use the bushes for defecation then we can prevent

diarrhoea and that is why I decided to construct my latrine in order to avoid diarrhoeal

diseases”.
 38

4.3.5 Diseases suffered by household members in the past two weeks

Majority 152 (72%) of the diseases that members of the study population had suffered

from in the past two weeks were sanitation related (diarrhoea, typhoid, skin and eye

infections) as presented in Figure 4.5 below. A ranking done in the FGDs revealed

that 48 out of the 52 participants (92%) mentioned that sanitation related diseases

were among the top ten diseases that affected this community, a finding that was

similarly reported by the District Public Health Officer who mentioned that the study

area had a high prevalence of sanitation related diseases.

Figure 4.5: Diseases suffered by household members in the past 2 weeks (N=210)

4.3.6 Promoters of latrine construction and use in the study area

As presented in figure 4.6 below, the household survey findings indicated that there

was low 57 (27%) involvement of the Government in promoting latrine construction

and use in the study area. These findings were similar to those reported during the

various community wide discussions in the FGDs where Non-Governmental

 39

Organizations (NGOs) were mentioned to be the main promoters of latrine

construction and use in the study area.

Figure 4.6: Promoters of latrine construction and use (N=210)

4.3.7 Latrine construction financing

As presented in Figure 4.7 below, majority 15 (83%) of the latrines in the study area

were constructed with external support in the form of subsidies such as materials,

labor, finances, slabs among others; these subsidies were mainly from NGOs.

Figure 4.7: Financing for latrine construction (N=18)

 40

4.4 Knowledge and attitudes on latrine use

4.4.1 Knowledge on causes and transmission of diarrhoea

Overall, 76% of the study respondents reported that human faeces was the principal

source or diarrhoea with 82% reporting that children’s faeces can similarly cause

diarrhoea. Regarding the link between open defecation and diarrhoeal diseases,

majority (63%) reported that open defecation caused diarrhoeal diseases and a further

69% of the respondents believed that they were at risk of getting diarrhoea if their

neighbor did not use a latrine.

Most (67%) of those interviewed reported the correct causes of diarrhoea such as

eating food or drinking fluids contaminated with faeces, not washing hands, not using

latrines among others compared to the others (33%) who mentioned incorrect causes

such as-mosquito bites, witchcraft, rain among others. The findings related to

knowledge on cause and transmission of diarrhoea are summarized in Table 4.2

below.

Table 4.2: Knowledge on causes and transmission of diarrhoea

Knowledge variables (N=210) N %
Human faeces is the principle source No 51 24%
of diarrhea Yes 159 76%
Children's faeces can cause diarrhoea No 38 18%
Yes 172 82%
Effect of open defecation Shame & Disgust 78 37%
Diarrhoeal diseases 132 63%
Risk of getting diarrhoea if neighbor No 66 31%
practices open defecation Yes 144 69%
Causes of diarrhoea Correct causes mentioned 140 67%
In correct causes mentioned 70 33%
 41

4.4.2 Knowledge on prevention of diarrhoea

As presented in Table 4.3 below, majority (60.0%) of the respondents reported the

correct methods of diarrhoea prevention such as good food and water hygiene

practices, hand washing and using latrines compared to the others (40%) that

mentioned incorrect diarrhea prevention methods such as use of mosquito nets and

washing clothes. In addition, majority (74.3%) of the study respondents reported that

hand washing with water and soap everyday could prevent diarrhoea.

Table 4.3: Knowledge on prevention of diarrhoea

Knowledge variables (N=210) N %
Correct prevention methods 126 60.0%
Diarrhoea prevention methods mentioned
Incorrect prevention 84 40.0%
methods mentioned
Daily hand washing with water and soap No 54 25.7%
can prevent diarrhoea Yes 156 74.3%

4.4.3 Knowledge on benefits of using latrines

As presented in Table 4.4 below, nearly all respondents (96.7%) reported that the

main problem attributed to lack of latrines was diarrhoeal diseases compared to 3.3%

who reported other problems such as stigma, shame, high medical expenses, smell

and flies. In addition, majority (82.4%) of the respondents mentioned privacy,

convenience, status or prestige as the main benefits of using latrines compared to only

17.6% that mentioned diarrhoea disease prevention.

Table 4.4: Knowledge on importance of latrines

Knowledge variables (N=210) N %
Problems of not using latrines Diarrhoeal diseases 203 96.7%
Others 7 3.3%
Main benefit of using latrines Diarrhoeal disease prevention 37 17.6%
Others 173 82.4%
 42

4.4.4 Latrine use attitudes

As presented in Figure 4.8 below, majority 187 (89%) of the respondents mentioned

cultural factors such as taboos, beliefs, migration and the pastoralist nature of the

community as the main obstacle to latrine use in the study area. Other reasons

mentioned included lack of tools, money and skills.

Figure 4.8: Obstacles to latrine use (N=210)

Various cultural perceptions, beliefs, taboos and traditions surrounding latrine use

were reported during the study. According to the area Chief, since ancestral times,

latrine use has generally been low in the study population which has for a long time

practiced open defecation.

The District Public Health Officer (DPHO) reported that culturally, the study

population are pastoralists who often move from place to place in search of water and

pasture for their livestock. Due to the nature of their lifestyle, constructing permanent

facilities for defecation has never been often considered a feasible priority forcing

them to resort to open defecation. Because the members of the study area are not
 43

farmers, it is difficult for them to own appropriate digging tools for latrine

construction. The DPHO also was reported that the community members could sell

their livestock to do anything else but not construct a latrine.

Cultural restrictions were reported on latrine use. There was a general belief that

morans (young Samburu warriors) do to not use latrines as they were perceived to be

warriors who do not defecate. According to a male FGD participant, a Moran was

described as a young village warrior whose lifestyle was characterized by a lot of

mystery and privacy. Morans were therefore perceived as “bush” men and as such,

they do not eat or drink from the manyattas (Samburu traditional house) and because

they do not eat or drink in the manyattas, it is believed that where they eat and drink

(the bushes) it is where they should defecate. Culturally, it was an omen for Morans to

be seen to go into defecation bushes or latrines least of all by women as this was

viewed as a sign of weakness yet they were a symbol of strength in their community.

Other cultural restrictions also prohibited older men from sharing latrines with women

or their in laws.

The reasons provided for the widespread practice of open defecation were varied: it

was the norm in the community and as such the only option available, no one could

see you as the bushes could hide someone, bushes provided plenty of fresh air, and

there were plenty of open fields and gullies which presented adequate conditions for

open defecation among others. Describing the act of open defecation, one female

participant from the study area reported in an FGD: “almost everyone in my

community defecates in the open, we have no time to think about latrines and after all,
 44

we have a lot of bushes and gullies with plenty of fresh air, why would I want to enter

a house to defecate?, this is against my culture”.

It was also reported that the study population associated latrines with a typical modern

house and they therefore believed that it was shameful and culturally not appropriate

to construct a house to just put feaces in it. The digging of a latrine pit to just bury

one’s faeces was considered to be too much work while other priorities like taking

care of their livestock awaited them. One of the male FGD participants reported that

“if you put faeces in a “house” (latrine), what will the dogs eat?” It was also believed

that it was an omen for someone to dig a pit and leave it open even for a short time as

the open pit was associated with “inviting death”. Others also perceived latrines as

dirty places, which harbored evil spirits. The association of latrine use with

abandonment of their strong culture compounded the problem further.

4.5 Latrine use hygiene practices

Transect walks and the observation checklists were used to assess the various latrine

hygiene practices in the study area. Observations were made to assess the level of

latrine cleanliness, privacy and availability of a hand washing facility with water and

soap for hand washing. As presented in Table 4.5 below, slightly more than half

(55.6%) of the responding households had latrines that hygienically separated human

excreta from human contact, 66.7% of all observed latrines had a convenient source

of water and soap for hand washing, almost all (94.4%) observed latrines were found

to be clean during the study and 77.8% of the households had latrines that offered

adequate conditions of privacy.

 45

Table 4.5: Latrine use hygiene practices at the household level

Latrine hygiene practice variables (N=18) N %
Latrine hygienically separates human excreta No 8 44.4%
from contact Yes 10 55.6%
Latrine has water and soap for hand washing No 6 33.3%
Yes 12 66.7%
Latrine presents adequate conditions of No 1 5.6%
cleanliness Yes 17 94.4%
Latrine presents adequate conditions of privacy No 4 22.2%)
Yes 14 77.8%

4.6 Socio-demographic variables associated with latrine use

Out of the seven socio demographic variables investigated, five had a statistically

significant relationship with latrine use, they included: area of residence (p=0.001),

occupation (p=0.001), education (p=0.001), income (p=0.033), and gender of

household head (p=0.040).

The study found out that latrine use was higher among households living near market

centres such as Swari (17.6%), male headed households (8.7%), those who had

attained either primary or secondary education (40%) and also among those with lower

income levels (7%). However, latrine use was observed to be lowest among livestock

keepers (0.6%). There was no association between latrine use and the age of the

household head (p=0.783) and the household family size (p=0.070). Results in Table

4.6 present the socio demographic characteristics of the study respondents and how

they were associated with latrine use.

 46

Table 4.6: Socio-demographic variables associated with latrine use

Socio Demographic variables Latrine No latrine Total χ² df p Value
(N=210) use use
Area of Within or near Swari 13 (17.6%) 61 (82.4%) 74 (100%)
residence market centre
0.001**
Outside Swari market 1 (0.7%) 135 (99.3%) 136 (100%)
centre
Gender Male 8 (8.7%) 84 (91.3%) 92 (100%)
1.083 1 0.040*
Female 6 (5.1%) 112 (94.9%) 118 (100%)
Age 30 to 40 years 5 (5.8%) 81 (94.2%) 86 (100%)
0.170 1 0.783*
More than 40 Years 9 (7.3%) 115 (92.7%) 124 (100%)
Occupation Livestock Keeping 1 (0.6%) 167 (99.4%) 168 (100%)
Employed or in 13 (31%) 29 (69%) 42 (100%) 0.001**
trading business
Level of None 4 (2.2%) 181 (97.8) 185 (100%)
education 0.001**
Primary & Secondary 10 (40%) 15 (60%) 25 (100%)
Income Less than Ksh. 5,000 13 (7%) 165 (93%) 178 (100%)
0.033**
More than Ksh. 5,000 1 (3%) 31 (97%) 32 (100%)
Household 1 to 6 people 6 (4.2%) 137 (95.8%) 143 (100%)
size 4.398 1 0.070*
7 and more people 8 (11.9%) 59 (88.1%) 67 (100%)
Total 14 (6.7%) 196 (93.3%) 210 (100%)
* Chi Square ** Fisher’s Exact Test

4.7 Knowledge and attitudes associated with latrine use

4.7.1 Knowledge on causes of diarrhoea associated with latrine use

A total of 5 knowledge related factors on the causes of diarrhoea were studied out of

which, 4 had a statistically significant relationship with latrine use. Latrine use was

higher among households that had the correct knowledge on: human faeces being the

principle source of diarrhoea (p=0.046), open defecation being able to cause diarrhoea

(p=0.019), risk of getting diarrhoea if neighbor was not using latrines (p=0.006) and

the causes of diarrhoea (p=0.006). The detailed findings are presented in Table 4.7

below.
 47

Table 4.7: Knowledge on causes of diarrhoea associated with latrine use

Knowledge variables (N=210) Latrine No latrine Total Fisher's
use use Exact Test
p Value
Human faeces is the No 2 (3.9%) 49 (96.1%) 51 (100%)
principle source of Yes 12 (7.5%) 147 (92.5%) 159 (100%) 0.046
diarrhea
Children's faeces can No 1 (2.6%) 37 (97.4%) 38 (100%)
cause diarrhea 0.473
Yes 13 (7.6%) 159 (92.4%) 172 (100%)
Effect of open Shame & 1 (1.3%) 77 (98.7%) 78 (100%)
defecation Disgust
0.019
Diarrhoeal 13 (9.8%) 119 (90.2%) 132 (100%)
diseases
Risk of getting No 0 (0%) 66 (100%) 66 (100%)
diarrhoea if neighbor
0.006
practices open Yes 14 (9.7%) 130 (90.3%) 144 (100%)
defecation
Causes of diarrhoea Correct causes 14 (10%) 126 (90%) 140 (100%)
mentioned
In correct 0 (0%) 70 (0%) 70 (100%) 0.006
causes
mentioned
Total 14 (6.7%) 196 (93.3%) 210 (100%)

4.7.2 Knowledge on prevention of diarrhoea associated with latrine use

Respondents that reported the correct diarrhoea prevention methods had statistically

significant (p=0.049) higher latrine use (9.5%) compared to those who did not

(2.4%). In addition, all respondents who were using latrines (9%) perceived that daily

hand washing with water and soap could prevent diarrhoeal diseases (p=0.023). Both

of these findings were statistically significant as presented in Table 4.8 below.

 48

Table 4.8: Knowledge on prevention of diarrhoea associated with latrine use

Fisher's
Knowledge variables (N=210) Latrine No latrine Total Exact
use use Test
p Value
Correct 12 (9.5%) 114 (90.5%) 126 (100%)
Diarrhoea prevention
prevention methods methods
mentioned
Incorrect 2 (2.4%) 82 (97.6%) 84 (100%)
prevention 0.049
methods
mentioned
Daily hand washing No 0 (0%) 54 (100%) 54 (100%)
with water and soap Yes 14 (9%) 142 (91%) 156 (100%)
can prevent diarrhea
0.023
Total 14 (6.7%) 196 (93.3%) 210 (100%)

4.7.3 Knowledge on latrine benefits associated with latrine use

Respondents that reported that the main benefit of using latrines was to prevent

diarrhoeal diseases had statistically significant (p=0.010) higher latrine use (16.2%)

compared to those who did not (4.6%) as presented in Table 4.9 below. There was no

association between latrine use and the problems attributed to not using latrines

(p=0.072).

Table 4.9: Knowledge on latrine benefits associated with latrine use

Knowledge variables Latrine No latrine Total χ² df p
(N=210) use use Value
Problems of Diarrhoeal 12 (5.9) 191 (94.1%) 203 (100%)
not using diseases 0.072**
latrines Others 2 (28.6%) 5 (71.4%) 7 (100%)
Main Diarrhoeal 6 (16.2%) 31 (83.8%) 37 (100%)
benefit of disease
using prevention 6.583 1 0.010*
latrines Others 8 (4.6) 165 (95.4%) 173 (100%)
Total 14 (6.7%) 196 210 (100%)
(93.3%)
* Chi Square ** Fisher’s Exact Test
 49

4.8 Hygiene practices associated with latrine use

A total of four hygiene practices related to latrine use were studied out of which three

had a statistically significant relationship with latrine use. Households that were using

improved latrine facilities during the study demonstrated several appropriate hygiene

practices related to latrine use. Latrine use was found to be higher among households

that had latrines that hygienically separated human excreta from human contact

(p=0.023), had a convenient source of water and soap around the latrine (p=0.005) for

hand washing and those that presented adequate conditions of privacy (p=0.001)

findings which are presented in Table 4.10 below.

Table 4.10: Hygiene practices associated with latrine use

Latrine hygiene practice Latrine use No latrine use Total Fisher's
variables (N=18) Exact Test
p Value
Latrine hygienically No 4 (50%) 4 (50%) 8 (100%)
separates human excreta 0.023
from contact Yes 10 (100%) 0 (0%) 10 (100%)
Latrine has water and No 2 (33.3%) 4 (66.7%) 6 (100%)
0.005
soap for hand washing Yes 12 (100%) 0 (0%) 12 (100%)
Latrine presents adequate No 0 (0%) 1 (100%) 1 (100%)
conditions of cleanliness 0.054
Yes14 (82.4%) 3 (17.6%) 17 (100%)
Latrine presents adequate No 0 (0%) 4 (100%) 4 (100%)
0.001
conditions of privacy Yes 14 (100%) 0 (0%) 14 (100%)
Total 14 (77.8%) 4 (22.2%) 18 (100.0%)

4.9 Factors associated with promoting latrine use

4.9.1 Living in close proximity to market centres

As presented in Table 4.11, households that lived near main market centres such as

Swari had statistically significant (p=0.001) higher (17.6%) latrine use compared to

those that resided outside the market centres (0.7%).

 50

Table 4.11: Factors associated with promoting latrine use

Factors promoting latrine use N=210 Latrine No latrine Total Fisher's
use use Exact Test
p Value
Living close to Swari Yes 13 (17.6%) 61 (82.4%) 74 (100%)
market centres 0.001
No 1 (0.7%) 135 (99.3%) 136 (100%)
Clearly defined gender Women 14 (7.1%) 184 (92.9%) 198 (100%)
roles - gender Men 0 (0%) 12 (100%) 12 100% 0.001
responsible for
constructing latrines
Total 14 (6.7%) 196 (93.3%) 210 (100%)
Factors promoting latrine use N=18
Clearly defined gender Men 0 (0%) 1 (100%) 1 (100%)
roles - gender Women 14 (82%) 3 (18%) 17 (100%) 0.582
responsible for cleaning
latrine
Provision of subsidies in No 1 (33.3%) 2 (66.7%) 3 (100%)
construction of current Yes 13 (86.7%) 2 (13.3%) 15 (100%) 0.043
latrine
Main Motivation for Diarrhoeal 13 (92.9%) 1 (7.1%) 14 (100%)
constructing and using disease
current latrine prevention
Health 1 (25%) 3 (75%)) 4 (100%)
0.004
education
received or
influence from
neighbors
Total 14 (77.8%) 4 (22.2%) 18 (100%)

4.9.2 Clearly defined gender roles

There was a statistically significant relationship (p=0.001) between latrine use and

gender responsible for latrine construction; latrine use was higher (7.1%) among

respondents that reported women were responsible for constructing latrines in their

community. There was no association (p=0.582) between latrine use and gender

responsible for latrine cleaning as presented in Table 4.11.

 51

4.9.3 Provision of subsidies in latrine construction

As presented in Table 4.11, households that had received subsidies in latrine

construction had statistically significant (p=0.043) higher latrine use (86.7%)

compared to those that had used their own resources to finance the construction of

their latrines (33.3%).

4.9.4 Motivation for latrine construction and use

Among those with latrine use, respondents that reported that the main motivation for

constructing and using latrines was to prevent diarrhoeal diseases had statistically

significant (p=0.004) higher latrine use (92.9%) compared to those who mentioned

health education and influence from neighbors as main motivation (25%). The

findings are presented in Table 4.11.

A further analysis of diseases that members of the household had suffered from the

past two weeks revealed that, households that had a member of their family who had

suffered from other diseases that were not related to sanitation in the past two weeks

such as Upper Respiratory Tract Infections (URTI), HIV/AIDS, Cough etc. had

statistically significant (p=0.011) higher latrine use (21%) compared to those

households that had a member who had suffered from sanitation related diseases (1%)

such as typhoid, diarrhoea, skin and eye infections as presented in Table 4.12 below.
 52

Table 4.12: Diseases suffered in the past two weeks associated with latrine use
Disease variable (N=210) Latrine No latrine Total Fisher's
use use Exact
Test
p Value
Diseases Sanitation 2 (1%) 150 (99%) 152 (100%)
members of related
household diseases 0.011
suffered from in Others 12 (21%) 46 (79%) 58 (100%)
the past 2 weeks
Total 14 (6.7%) 196 (93.3%) 210 (100%)

4.10 Factors associated with hindering latrine use

4.10.1 Cultural beliefs, taboos and traditions

As presented in Table 4.13, respondents that mentioned cultural factors as the major

obstacle to latrine use had statistically significant (p=0.002) lower latrine use (1%)

compared to those who mentioned lack of tools, money and skills as the main

obstacles (52%).

4.10.2 Perceived poverty levels

There was a statistically significant relationship between level of income and latrine

use (p=0.033). The study found out that latrine use was higher among the low income

earners (7%) compared to the high income earners (3%) as presented in Table 4.13.

4.10.3 High illiteracy levels

As presented in Table 4.13, the study findings revealed that there was a statistically

significant relationship between education level of household head and latrine use
 53

(p=0.001). The study found out that latrine use was higher among respondents with

either primary or secondary level of education (40%) compared to those who has no

formal education (2.2%).

Table 4.13: Factors associated with hindering latrine use

Factors hindering latrine use Latrine No latrine use Total Fisher's
N=210 use Exact
Test
p Value
Obstacles to Lack of tools, 12 (52%) 11 (48%) 23 (100%)
latrine money, skills
construction and Cultural 2 (1%) 185 (99%) 187(100%) 0.002
use taboos, beliefs
and practices
Income Less than Ksh. 13 (7%) 165 (93%) 178 (100%)
5,000
0.033
More than 1 (3%) 31 (97%) 32 (100%)
Ksh. 5,000
Literacy level None 4 (2.2%) 181 (97.8) 185 (100%)
Primary & 10 (40%) 15 (60%) 25 (100%) 0.001
Secondary
Possession of Yes 1 (1.4%) 73 (98.6) 74 (100%)
latrine No 13 (9.6%) 123 (90.4%) 136 (100%) 0.022
construction
skills
Promoters of Government 1(2%) 56 (98%) 57 (100%)
latrine NGOs 13 (8%) 140 (92%) 153 (100%) 0.002
construction and
use
Gender Women 14 (7.1%) 184 (92.9%) 198 (100%)
responsible for Men 0 (0%) 12 (100%) 12 100% 0.001
constructing
latrines
Total 14 (6.7%) 196 (93.3%) 210 (100%)
Factors hindering latrine use N=18
Source of Own 1 (33.3%) 2 (66.7%) 3 (100%)
financing for the resources
0.043
construction of NGO’s 13 (86.7%) 2 (13.3%) 15 (100%)
current latrine
Total 14 (77.8%) 4 (22.2%) 18 (100%)
 54

4.10.4 Lack of latrine construction skills

The study observed that respondents that lacked latrine construction skills had

statistically significant (p=0.022) higher latrine use (9.6%) compared to those who

had latrine construction skills (1.4%) (Table 4.13).

4.10.5 Low government involvement in promoting latrine use

Respondents that mentioned NGO’s as the main organizations that promoted latrine

use in the study area had statistically significant (p=0.002) higher latrine use (8%)

compared to those who mentioned the government (2%). These findings are presented

in Table 4.13.

4.10.6 Low involvement of men in latrine related matters

Overall, there was no latrine use in all households who mentioned that men were

responsible for constructing latrines in their communities; findings which were

statistically significant (p=0.001) (Table 4.13).

4.10.7 Low self-initiation of latrine construction

As presented in Table 4.13, households that had initiated the construction of their

latrines using their own resources had statistically significant (p=0.043) lower

latrine use (33.3%) compared to those that had received subsidies for latrine

construction (86.7%).
 55

CHAPTER FIVE: DISCUSSION, CONCLUSION AND

RECOMMENDATIONS

5.1 Introduction

This chapter provides an in-depth discussion and key deductions made from the

significant findings that emanated from this study in addressing the study objectives

and research questions. The chapter also details the main conclusions and

recommendations drawn from the significant findings of the study as well as the areas

for further research.

5.2 Discussion

5.2.1 Socio-demographic characteristics of the study population

The study found out that latrine use was highest among households that lived in or

near the market centres such as Swari. This could be attributed to the fact that Swari

sub location had the largest and more established market centre compared to the

others. This implied that living in close proximity to market centres necessitated the

need to have latrine facilities considering that most traders were doing business for

the better part of the day. These findings were consistent with those reported by

Shakya et al. (2012) which indicated that living in close proximity to main cities was

found to increase latrine use.

Although the study recorded more female than male headed households, latrine use

was observed to be higher among male headed households than female headed

households. Similar findings were reported by UNDP (2006), Kema, (2012), Awoke

and Muche (2013) who observed that male headed households had higher latrine use.
 56

The study further established that in this community, women bear the burden of

cleaning and constructing latrines. More gender awareness on shared responsibilities

in latrine related matters may be necessary to bridge this apparent gap.

The type of occupation of the household head provides useful insights into the

economic status of the household which ultimately affects the key decisions made for

the household. The study found out that majority of the people in the study area were

livestock keepers. It was reported by all participants in all the FGDs and KIIs that the

livelihood of the study community was livestock keeping, an occupation characterized

by periodic migration with livestock from place to place in search of water and

pasture. Latrine use was lowest among the livestock keepers which could be attributed

to their nomadic nature of life. As reported by a male participant in the FGDs, due to

their nomadic way of life, the study community hardly constructs or uses latrines as

they are accorded very low priority. Their migration lifestyle is compounded further

by the long distances travelled meaning that they only prioritize their livestock and as

long as their livestock are well fed and watered, nothing else was of priority. More

appropriate latrine solutions such as movable light weight latrine plastic slabs might

be more ideal for pastorolist communities as they can be able to move with them from

place to place as they look for water and pasture.

The level of education of the household head has a direct bearing on the health related

decisions made for the household as well as adoption of good latrine related practices.

The study population exhibited high illiteracy rates; latrine use was higher among

households with either primary or secondary level of education compared to those

without any formal education. This could be attributed to the impact that education
 57

makes in decision making for ultimate behavior change and adoption of good latrine

practices at the household level. According to the District Public Health Officer, the

low latrine use rates for the study area could be attributed to the low literacy rates of

the study population which was a major impediment to the overall development of the

study area.

The average monthly income of a household is an important indicator of a

household’s ability to afford a latrine facility as well as affects other day to day

decisions made in the family. A unique finding from the study was that low income

respondents had higher latrine use compared to the high income earners. This could

be attributed to the fact that majority of the households in the study area had

constructed their latrines through external assistance in the form of subsidies mostly

from NGOs. Subsidies provided included: materials, labor, finances, latrine slabs

among others. This finding implied that higher income levels did not necessarily

translate into ownership and use of a latrine facility in this community and other

underlying factors could have had a greater influence on latrine use other than

income. This study finding is not consistent with those of UNDP (2006) which

identified poverty as a key contributor to latrine inequalities, the Water Sanitation

Programme (2004) that found out that limited financial ability was a major hindrance

to up scaling latrine use and Kema, (2012), Awoke and Muche (2013) that found out

that a household’s monthly income positively promoted ownership and use of latrine

facilities.
 58

5.2.2 Knowledge and attitudes on latrine use

The study found out that generally, where latrine use was high, majority of the

respondents exhibited the correct knowledge linking latrines to diarrhoeal disease

prevention compared to their counterparts with lower latrine use. For instance,

majority believed that: one was at risk of getting diarrhoea if their neighbor practiced

open defecation, open defecation was associated with diarrhoeal diseases, human

faeces was the principal source of diarrhoea, hand washing with water and soap

everyday could prevent diarrhaea and that latrine use could prevent diarrhoeal

diseases. In addition, majority also reported the correct causes and prevention

methods of diarrhoea. The study differs with findings from the Water Sanitation

Programme (2004) that indicated that lack of awareness on sanitation and hygiene

were key hindrances to up scaling latrine use as this study established that the

knowledge levels related to latrine use were generally high yet the practice of actually

using latrines remained low compared to the global and national targets.

The study therefore implies that although the community exhibited higher levels of

knowledge pertinent to latrines and diarrhoeal disease, this knowledge was yet to

translate into practice among the wider community members in the study area. This

indicates an apparent gap in knowledge, awareness and practice that may need to be

bridged in future by encouraging communities to translate their knowledge and

awareness levels into the practice of constructing and using latrines.

 59

5.2.3 Latrine use hygiene practices

Majority of the households with higher latrine use had adopted appropriate good

latrine hygiene practices such as having a latrine that hygienically separated human

faeces from human contact, having a hand washing facility with water and soap

outside the latrine and having latrines that offered adequate privacy. The hygienic

maintenance of latrine facilities has the potential to increase use as well as confer

additional health benefits since when human excreta is kept away from contact, then

smell and flies can be minimized. The lack of visible excreta on the latrine surface is

one way of ensuring that the feacal oral disease transmission route is broken.

The adoption of appropriate latrine practices at the household level promotes

subsequent use of latrine facilities due to the aesthetic values assigned to use of

latrines implying that a “nice” latrine based on privacy and cleanliness criteria were

more likely to be used. The study notes that although a small section of the

community were using improved latrines; still the vast majority was yet to abandon

the practice of open defecation. More awareness may need to be created within this

community to enable the larger segment of the population construct and use latrines.

5.2.4 Factors that promoted latrine use in the study area

5.2.4.1 Clearly defined gender roles

Gender refers to the socio culturally assigned roles and responsibilities to males and

females in a given community. Gender role definition helps in clarifying who does

what in a certain community and is more likely to streamline the various community

operations and household related activities. In most communities in Kenya, cleaning

 60

of latrines is largely a women’s affair, results which were not any different from this

study as all respondents reported that women were responsible for cleaning latrines.

Similarly, in most communities, the more labor intensive roles are often assigned to

men. However among this study community, it was noted that the more labor

intensive work of constructing latrines rested solely on women. The study deduces

that although clear definition of gender roles helps in streamlining the day to day

operations in a particular community, there may be need for more gender awareness

to advocate for shared responsibilities in order to increase the participation of all

segments of the population in matters related to latrine construction and cleaning at

the household and community levels for increased latrine use.

5.2.4.2 Motivation for latrine construction and use

Majority of the households members who were using latrines had constructed them to

prevent diarrhoeal diseases. These findings differed with those of Jenkins, (2007) that

indicated that a household’s decision to adopt the use of latrines had little to do with

the prevention of faecal-oral diseases. In addition, these findings resonate well with

the health belief model that indicates that a person is more likely to adopt new

behaviors in this case construct and use latrines if the benefits outweighed the

perceived risks (FHI, 1996). The motivations for latrine construction and use

identified in the study provide room to further explore their replicability and up

scaling to all areas with low latrine use.

Majority of the diseases that members of the study population had suffered from in

the past two weeks were sanitation related; latrine use was highest among households

that had not suffered any sanitation related disease in the past two weeks. Among
 61

those who lacked latrine use, majority of them reported to have had a member of their

household who had suffered from sanitation related diseases. This clearly indicates

the significant role that latrines can play in breaking the faecal – oral disease

transmission route.

5.2.4.3 Provision of subsidies in latrine construction

The role of external actors especially NGOs in promoting latrine use was noted to be

significant. In this study, provision of subsidy for latrine construction was categorized

as any form of assistance provided to a household in the form of finances, labor or

technical support as well as provision of latrine construction materials. Majority of the

latrines in the study area were constructed with external support mostly from NGOs.

These findings are similar to those reported by Kema, (2012), Awoke and Muche

(2013) that indicated external assistance was found to promote latrine use.

The study however notes that the provision of external subsidies possess as a potential

risk to sustainability of latrine projects in communities since the continued provision

of external support will ultimately increase latrine use but may end up weakening the

community capacities to sustain the action after withdrawal of the support as

evidenced in the study by the lack of latrine construction skills among a majority of

the households with latrines. This could be attributed to the high dependency

syndrome that comes with any form of continued widespread incentives which may

hinder sustainability. The increased dependency on subsidies weakens the

sustainability and community capacities to initiate and manage latrine interventions

on their own. The study deducts that until a household decides that using a latrine
 62

facility is of priority to them and takes action to construct and use it, only then can

sustainable improvements in up scaling latrine use be made.

5.2.4.4 Living in close proximity to market centres

The study found out that most people with latrines resided in Swari Sub Location

which could be attributed to the fact that Swari sub location had the largest and more

established market centre compared to the others. This implied that living in the

market centres necessitated the need for latrine facilities considering that most traders

in the markets were doing business for the better part of the day. These findings are

consistent with those reported by Shakya et al. (2012) which indicated that living in

close proximity to main cities was found to increase latrine use.

5.2.5 Factors that hindered latrine use in the study area

5.2.5.1 Cultural beliefs, taboos and traditions

This study found out that cultural factors and associated beliefs, taboos and traditions

were the main hindrances to latrine use in the area of study. The study results were

consistent with the Water Sanitation Programme (2004) findings that identified

nomadic pastoralism and cultural factors to be major hindrances to improved latrine

ownership and use. According to most participants in the FGDs, the use of latrines

was ultimately associated with the abandonment of the communities’ culture. The

strong cultural inhibitions to latrine use implied that there was an urgent need to

design and implement latrine projects that were culturally acceptable to the study

population. In addition, efforts to upscale latrine use must be geared towards

 63

addressing the social cultural barriers (beliefs and practices) in order to upscale latrine

use.

5.2.5.2 Perceived poverty levels

The study observed that latrine use was higher among low income earners compared

to the high income earners. These findings differed with those of UNDP (2006) that

identified poverty as a key contributor to latrine inequalities, those by the Water

Sanitation Programme (2004) that showed limited financial ability to be major

hindrances to up scaling latrine use as well as those of Kema, (2012), Awoke and

Muche (2013) that indicated that a household’s monthly income positively promoted

use of latrine facilities.

The “perceived poverty” mentality requires further de-mystifying. Although the

income level findings paint a grim poverty picture on the target population, the

District Public Health Officer clarified that most of the members of the study area

were not as poor as the general perception has been. This was because, majority of the

community members were livestock keepers who owned several heads of livestock

and if the same was to be converted into liquid cash, they would fetch a higher market

value. Further, it was reported that a typical “poor household” in the study area may

not equate to any other poor household elsewhere because of their livestock wealth.

Interestingly, it was reported that the community members could sell their livestock to

do anything else but not construct a latrine. The concept of “perceived poverty”

among the pastoralists communities is not new, however what is lacking is raising the

awareness among the study population on how to convert their livestock into real cash

which can ultimately be utilized to construct latrines as opposed to provision of

subsidies.
 64

5.2.5.3 High illiteracy levels

As confirmed by the household and KIIs during the study, the study population

exhibited high illiteracy rates. Latrine use was lower among households without any

formal education compared to their counterparts who had attained primary or

secondary level of education. This could be attributed to the impact that education

makes in decision making for ultimate behavior change and adoption of good latrine

hygiene practices at the household level. According to the District Public Health

Officer, the low latrine use rates for the study area was largely attributable to the high

illiteracy rates in the study area which was a major impediment to the overall

development of the study area.

5.2.5.4 Lack of latrine construction skills

The possession of the relevant latrine construction skills is prerequisite if the said

latrine facility is to be sustainably utilized, repaired or replaced (operation and

maintenance requirements) in a hygienic manner. The study observed that majority of

the people in the study area did not have the necessary skills for constructing latrines

yet, latrine use was highest among these households that lacked the necessary skills

for constructing latrines. This could be attributed to the fact that majority of the

households had constructed their latrines with external assistance which included

provision of finances, materials, slabs or labor in latrine construction.

The lack of latrine construction skills particularly may hinder households from

constructing or repairing their latrines as many would opt without and may hinder

sustainability of future latrine projects. Similar to findings by the Water Sanitation

 65

Programme (2004), this study identified the lack of knowledge on how to construct

latrines to be a major hindrance to up scaling latrine use.

When asked about their ability to construct latrines, most of the FGD participants

indicated that they had the strength to construct latrines but often they lacked skills

and technical knowledge on how to construct latrines as majority were pastoralists

that had never used or constructed latrines before. This implied that there was an

urgent need for all actors to invest in building capacities of communities in order to

have inherent skills to be able to construct, repair or replace their latrines in future as

opposed to giving subsidies which is often not sustainable.

The provision of external support in latrine construction as opposed to strengthening

community capacities to construct latrines on their own may hinder sustainable

functionality of latrine facilities in the long term. When communities do it on their

own, then they learn and are more able to repair or replace their latrines in future as

the skills will be inherent within their communities. As was reported during the

community wide discussions in the FGDs, use of latrines in the study area was not a

very common practice implying that the community required intensive capacity

building in order to understand how to construct, use and maintain their latrine

facilities.

5.2.5.5 Low government involvement in promoting latrine use

The low involvement of the government in promoting latrine construction and use in

this community stands out. This in itself may hinder sustainability of latrine actions in

the community where the main drivers of change were external actors such as NGOs
 66

as opposed to internal actors such as the government. The findings were consistent

with the UNDP (2006) report that indicated the low prioritization of latrines by

Governments as a key barrier to increasing latrine use. The government being the

custodian of sanitation related policies has a special position in the country to

advocate for increased latrine use. More resources need to be allocated to the

sanitation sector which has been consistently underfunded in the past. Therefore more

strategic advocacy and increased funding to the sanitation sector by the Government

will raise the sanitation profile in the area of study and is a first step in addressing the

persistent sanitation inequalities in the study area.

5.2.5.6 Low involvement of men in latrine related matters

As already reported, latrine matters ranging from construction and cleaning in the

study area was largely a women’s affair although the latrines were used by almost

everyone in the family. Although clear gender roles as prescribed by the social norms

within a community suffice, there needs to be more advocacy to increase the role of

men in latrine related matters as often they are the decision makers of most

households in charge of controlling a household’s resources (UNDP, 2006). It may

therefore be difficult for women to construct latrines without the consent of their male

counterparts neither will it be possible for the men to allocate a household’s economic

resources to latrine construction if they do not feel it is a priority for their household.

Since men are key decision makers, they have an unparalleled position within the

society to advocate for increased latrine use an opportunity that needs to be explored

further in future latrine programs.

 67

5.2.5.7 Low self-initiation of latrine construction

Only as small proportion of respondents had constructed their latrines using own

resources while a majority constructed their latrines with external support mostly

from NGO’s. Generally, people do not value or appreciate free things which more

often than not are misused and fail to be sustainable in the long term. Communities

have inherent solutions and are best able to determine which actions will enable them

to overcome their perceived barriers to development. Instead of focusing on the

provision of subsidies which often creates a dependency syndrome, communities need

to self-support themselves in order to change their attitudes and behavior through

community mobilization to stop open defecation, build and use latrines. When support

comes from within and not from outside, communities have better ownership of the

process and the benefits that will accrue from their collective actions. In addition,

when communities collectively commit to the necessary behavior change, they would

subsequently hold themselves and their peers accountable. Eventually, the

communities become fully empowered to own the desired change that comes as a

result of improved health due to improved latrine use and it is they who can be

credited for the success.

It is suggested that self-initiation of latrine construction should be explored as a more

sustainable way of increasing latrine use as opposed to provision of subsidies that

often leads to dependency syndrome among communities. Unless communities

prioritize latrine use on their own, all future external support will be futile. The study

notes that constructing latrines alone will not solve the sanitation challenge in the

study area, empowering local communities to solve their own problems is the best

way to improve latrine use and ultimately the health of communities.

 68

5.3 Conclusion

The study concludes that:

1) There was an apparent gap between the knowledge on latrines and the practice

of using latrines in the study area. This is because, although the study

observed that the knowledge levels related to latrine use, causes and

prevention of diarrhoea were high, majority of those interviewed were not

using latrine facilities.

2) Adoption of good latrine hygiene practices such as keeping the latrine clean,

providing water and soap for hand washing and providing adequate conditions

of privacy enhanced use of latrine facilities.

3) The study identified clearly defined gender roles, main motives for latrine

construction and use, provision of subsidies in latrine construction and living

in close proximity to market centres as factors that promoted latrine use in the

area of study.

4) The study established that cultural beliefs, taboos and traditions, high poverty

and illiteracy rates, lack of latrine construction skills, low government and

men involvement in promoting latrine construction and use and low initiation

of latrine construction as the main hindrances to latrine use in the study area.
 69

5.4 Recommendations

The study recommends that:

1) Proactive efforts need to be taken by all actors to bridge the apparent gap

between knowledge and practice pertinent to up scaling latrine use. Targeted

and thematic sanitation campaigns can be conducted to promote the

construction and use of latrine facilities focusing on latrine construction skills

enhancement.

2) The local stakeholders should identify households with good latrine hygiene

practices to become model homes for other community members to learn from

and emulate the good latrine hygiene practices observed. Villages that shall be

identified to have eliminated open defecation can be recognized and celebrated

to motivate them to maintain their Open Defecation Free (ODF) status.

3) Since the main motivation for using latrines was observed to be prevention of

diarrhoeal diseases, more awareness needs to be created on the impact of open

defection to motivate communities to construct and use latrines to prevent

diarrhoeal diseases

4) To accelerate progress towards attainment of sanitation targets in the area of

study, existing latrine construction and use barriers need to be addressed.

Specifically there is need to equip communities with latrine construction

skills, address social cultural barriers to latrine use and increase the

participation of men in latrine related matters as they can be key champions

and agents of change in promoting latrine use. The Government should

provide matching resources to tackle the sanitation disparities in the Sub-

County while utilizing socio-culturally appropriate technological options

suitable for the study community. Communities should also be encouraged to

 70

initiate the construction of their own latrines as opposed to waiting for external

help in the form of subsidies as this may not be sustainable in the long term.

5.5 Further research

1) The study recommends that an in depth formative research be undertaken to

explore how existing latrine use barriers can be addressed in order to upscale

latrine use in the study area

2) There is need to initiate research on effectiveness of sanitation marketing

approaches without the provision of subsidy as an approach geared towards up

scaling sustainable latrine use

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APPENDICES
Appendix 1: JMP Method of Categorizing Types of Latrine Facilities

Improved Latrine Facilities Unimproved Latrine Facilities

Ventilated Improved Pit (VIP) Pit latrines without a slab or

latrine platform that is open pit

Pit latrine with slab Hanging latrines or toilets

Composting toilet Bucket latrines

Flush or pour-flush toilet/latrine to: Flush or pour flush to elsewhere

 Piped sewer system (that is, not to piped sewer
 Septic tank system, septic tank or pit latrine)
 Pit latrine Public shared facilities of any
type
No facilities, bush or field

Source: (UNICEF and WHO, 2013)

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Appendix 2: Informed Consent Form

Informed consent

Hi. My name is Racheal Wanjiku Waithaka, a Masters student at Kenyatta University

and am here to conduct a study Latrine use and associated factors in rural Samburu
East Sub County, Samburu County, Kenya

The study is in partial fulfillment of my academic requirements. By participating in

the study, you will provide vital information that might help your community, local
partners or stakeholders and the government officials to undertake appropriate latrine
programmes suitable for the Samburu community with an understanding of the
underlying latrine associated factors.

It is for this purpose that I am kindly requesting for your participation by answering a
few questions related to the study which may take about 30 minutes of your time. In
case you choose to participate, your name or identity will not be revealed to anyone.
In addition, your participation in this study will not attract any financial rewards but
will be on voluntary basis, you can chose not to answer some of the question(s). Just
like those who may choose not to participate in answering any of these questions,
their decision will be respected. We assure you that the information you give will only
be used for purposes of this academic study.

Signature:
I have read/been read to the above consent statement and understood that my decision
to participate or not to participate in the study is voluntary and that I will not get
financial benefits by participating in this study.

Please, fill the following sub-section (If YES, proceed to Q1, if No, terminate
session by thanking the community member):

YES, I have agreed to participate: ________________ ____________

Signature/Right thumb Print Date

NO, I have refused to participate:________________ ____________

Signature/Right thumb Print Date

Person Administering Consent:

I __________________________, confirms that the above consent was read and

signed in my presence: ______________________ ____________
Signature/Right thumb Print Date
 77

Appendix 3: Household Questionnaire

Interviewer Initials Date

Household Number Questionnaire Code No
Sub Location Village

SECTION A: DEMOGRAPHIC INFORMATION

1. The household head is

Male 1 Female 2

2. Age of household head in complete year……………………………………..

3. What is the occupation of the household head?

Formal Employment (Salaried) 1 Livestock Keeping 4

Informal Employment (Casual) 2 Agriculture 5
Trading/Business 3 Other (specify)

4. What is the highest level of education of the household head?

No Formal Education 0 Secondary 2

Primary 1 Tertiary 3

5. What is the household’s average income per month in Kenya

Shillings………..
6. How many people in total live permanently in this household?) ……….……

SECTION B: LATRINE USE

7. Where do you defecate? (Observe and confirm if household has ownership

and use of improved latrine facilities)

Improved Latrine Unimproved Latrine

Facilities Facilities
Ventilated Improved Pit 1 Pit latrines without a slab or 5
(VIP) latrine platform that is open pit
Pit latrine with slab 2 Hanging latrines or toilets 6
Composting toilet 3 Bucket latrines 7
Flush or pour-flush 4 Flush or pour flush to 8
toilet/latrine to either: elsewhere (that is, not to piped
 Piped sewer system sewer system, septic tank or
 Septic tank pit latrine)
 Pit latrine Shared Facilities of any type 9
No facilities, bush or field 10
Other (Specify)
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8. Does your household have skills No 0 Yes 1

necessary for constructing latrines?

9. Who is responsible for

Men 1 Women 2
constructing latrines in your
household?

10. If your household does not have a latrine, what are the main reasons why
your household does not have a latrine?

Don’t want one 1 The family does not own the land 6
It is not a priority 2 Terrain is not appropriate 7
Don’t have enough money 3 It’s not part of our culture 8
Don’t know how to construct 4 Lack of knowledge/skills on how to 9
construct/use it
Don’t have enough physical space 5 Lack of construction materials 10
Not Applicable 11 12
Others (Specify)

THE FOLLOWING QUESTIONS (14 TO 31) ARE ONLY FOR THOSE

HOUSEHOLDS WITH A LATRINE. IF THE HOUSEHOLD HAS NO
LATRINE, SKIP THE FOLLOWING QUESTIONS AND GO TO SECTION C

11. Overall, how many people use this latrine facility?

One to Three 1 Four to Six 2 More than Six 3

12. Do members of your household Share this latrine facility with other
households?
No 0 Yes 1
(go to Q 16)

13. With how many households do you share this latrine facility with?

One to Three 1 Four to Six 2 More than Six 3

14. Are there people in your household who do not use the latrine?

No 0 Yes 1
(go to Q 18)
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15. If yes, who in your household does not use this latrine-Multiples answers
allowed

Children (Under Five) 1 Sick people 5

Men 2 Don't know 6
Women 3 Others 7
(Specify)
Pregnant women 4

16. Is the latrine currently being used?-check through observation

No 0 Yes 1
(go to Q 21)

17. If no, why is the latrine not being used?

The latrine is collapsed / fear of collapsing 1 Latrine is too far 4

The pit is already filled 2 Poor privacy 5
Poor cleanliness (insects, bad smell, etc) 3 Other (specify)

18. Does the latrine hygienically separate human excreta 1

from human contact?-(Check through Observation) No 0 Yes

19. Does the interviewer observe presence of a convenient source of water and
soap around the latrine (< 3 meters)?-(Check through Observation)

None 0 Hand washing device (with 2

water and Soap)
Hand washing device 1 Hand washing device (with 3
(with water only) water and ash)
Other (Specify)

20. Does the latrine present adequate conditions of cleanliness?-(check through

observation)

Not clean (Visible feces or urine on the floor) 0

Adequately clean (no visible feces or urine) 1
Poorly clean (some dirt, but no visible feces or 2
urine)
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21. Does the latrine present adequate conditions of privacy?-(check through

observation)
No privacy 0
Adequate privacy 1
Poor privacy 2

22. How did you finance the construction of your current latrine?
Own 1 Loan 2
Resources
Others - specify 3
23. Who is responsible for cleaning latrines in your household?

Men 1 Women 2

24. What was the Main Motivation for constructing and using this latrine?-
(Probe – do not prompt)

No Motivation 0 Health education received 3

Disease prevention 1 Don’t Know 4
Influence from my 2 Others (Specify)
neighbor/social pressure

SECTION C: LATRINE USE ASSOCIATED FACTORS

THE FOLLOWING QUESTIONS (32 TO 46) ARE FOR ALL HOUSEHOLDS

WITH OR WITHOUT A LATRINE FACILITY

25. What do you consider to be the Main Benefits of using a latrine?- (Probe do
not prompt)

No Benefit 0 Disease prevention 3

Privacy 1 Status or prestige 4
Convenience 2 Don’t Know 5
Others (Specify)

26. Who are some of the people who promote construction and use of latrines
in your community?

None 0 Local Leaders 4

Neighbor 1 NGOs 5
Community volunteers 2 Don’t Know 6
Government 3 Others (Specify)
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27. Are there any factors that are known to negatively influence latrine use in
your community?
No Yes
(go to Q 36) 0 (go to Q 35) 1

28. If yes, please tell me what are some of the factors that are known to negatively
influence latrine use in your community- (multiple answers allowed. Probe
do not prompt)

Social Factors List and explain all factors mentioned 1

Cultural Factors List and explain all factors mentioned 2

Religious Factors List and explain all factors mentioned 3

Others Specify List and explain all factors mentioned 4

29. In your opinion, what are the Major Obstacles to latrine ownership and
utilization in your community?- (multiple answers allowed)

Culture 1 Lack of Skills/Knowledge 4

Finances 2 Lack of land/Space 5
Unsuitable hydro-geological 3 Don’t Know 6
conditions
Others (Specify)

30. Do you think you are at risk of getting diarrhoea if your neighbor does not use
a latrine that is practices open defecation?

No 0 Yes 1

31. What is the effect of open defecation?

Causes shame/Disgust 1 Don’t Know 3

Causes diseases 2 Others (Specify)

32. Do you think Children’s feces can cause diarrhoea?

No 0 Yes 1 Don’t Know 2

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33. Do you think human feces are a principle source of diarrhoea?

No 0 Yes 1 Don’t Know 2

34. Do you think washing your hands everyday with soap and water could
prevent diarrhoea?

No 0 Yes 1 Don’t Know 2

35. In your opinions, what problems could be attributed to lack of latrine

facilities in your community?

None 0 Absenteeism from school 6

Diseases 1 Smell 7
Stigma 2 Flies 8
Indignity 3 Loss of productive time 9
Shame 4 Don’t Know 10
Medical Expenses 5 Other (Specify)

36. Which diseases have members of your household suffered from in the past 2
weeks?

Malaria 1 Eye infections 4

Diarrhoeal 2 Respiratory Tract 5
diseases Infections
Skin related 3 TB, HIV and AIDS 6
diseases
Others (Specify)

37. Can you please tell me some of the ways that one can get diarrhoea?
(Multiple answers allowed. Probe – do not prompt)

Eating food contaminated with feces 1 Not washing hands 5

Drinking fluids e.g. water 2 Not using latrines 6
contaminated with feces
Flies contaminated with feces settling 3 Don’t Know 7
on food/water
Eating with hands contaminated with 4 Others (Specify)
feces
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38. Can you please tell me some of the ways that one can Prevent diarrhoea?-
(multiple answers allowed. Probe – do not prompt)

Good Food Hygiene Practices (Proper cooking 1 Use of 4

and covering of food, washing fruits and latrines
vegetable etc)
Good Water Hygiene Practices (Treating drinking 2 Don’t Know 5
water, proper storage in clean containers etc)
Proper hand washing with soap and water 3 Others (Specify)

…………END OF SURVEY. THANK THE RESPONDENT………

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Appendix 4: Focused Group Discussion and Key Informant Guide

Interviewer Initials Date

FGD/KII Code No Sub Location

Village

Nature of Participant: (√ Tick appropriately)

FGD √ No. KII √ No.
Men Public Health Official
Women Administrative Official
(Chief/ Assistant
Chief/Village Elder)
Youth Key Opinion
Leader(businessman,
politician, Church elder etc
Others Specify Others Specify

Questions

SECTION A: LATRINE USE

1) How would you describe the general defecation habits of this community?
Probe further:
 What are your perceptions about latrine use in this community?
 What is the general level of latrine use in this community?

2) Have people in your community always had the same ideas about latrines?
How have they changed or how have they remained the same over time?

3) Are there people in your community who do not have latrines? What could
be the main reasons for this?

4) Are there groups of people in this community who are known not to use
latrines, what are some of the reasons?

5) For those people who have latrines in your community and do not use them,
what could be the reasons for non use of the latrines?

6) What are the general characteristics of people who own and use latrines in
this community

7) What are the general characteristics of people who do not own or use latrines
in this community?

8) Do you think people in this community have the capacity necessary to

construct latrine facilities? (skills, ability, materials, funds etc)
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9) Who are the main people who promote latrine use and construction in this
community and in what way? Whose responsibility do you think it is to
improve access to latrines in your community?

10) Who generally constructs and cleans latrines in this community?

SECTION B: LATRINE USE ASSOCIATED FACTORS

11) What do you consider to be the benefits of using a latrine or motivation for
constructing latrines?

12) In your opinions, what problems could be attributed to lack of latrine

facilities in your community?

13) Are there any factors that are known to negatively influence latrine use in
your community?

14) In your opinion, what are the major obstacles to latrine ownership and
utilization in this community?

15) What are your perceptions about open defecation? Main reasons for open
defecation? (Likes, Dislikes, is it harmful?)

16) What are your perceptions about handling children’s feces, can it cause
diarrhoea?

17) What are the major diseases that affect this Community?

18) Do you think you at risk of getting diarrhoea if your neighbor does not use a
latrine that is practices open defecation? Please explain

19) What are some of the ways one can get diarrhoea and how can diarrhoea be
prevented?

SECTION C: OTHERS
20) Are there any other issues that we may not have discussed related to latrines in
your area? Please tell me

…………END OF SURVEY. THANK THE RESPONDENT…………

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Appendix 5: Kenyatta University Ethics Review Committee Approval

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Appendix 6: National Commission of Science, Technology and Innovation

Research Authorization
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Appendix 7: National Commission of Science, Technology and Innovation

Research Clearance Permit