Investigating quality of shared sanitation facilities in informal settlements of Kisumu, Kenya

The sanitation target was not met during the MDG period, and as the SDG period begins, the goal still remains adequacy and equity in sanitation. Due to lack of space, achieving adequacy in informal settlements is challenging, and sharing of sanitation facilities is common. One concern with shared facilities is difficulty in cleanliness, and a lacuna exists in shared sanitation quality in informal settlements. This study investigated the quality of shared sanitation in informal settlements of Kisumu city in Kenya. Data was collected by interviewing users, and by inspecting sanitation facilities for aspects of quality. The facilities were all pit latrines, most of which offered privacy, but were not hygienically clean. Cleanliness deteriorated with more households sharing, indicating that less attention was given to keeping shared facilities clean. Improvement strategies in informal settlements should not only focus on access but also target group behaviour and practices among shared sanitation users

Decision-making on shared sanitation in the informal settlements of Kisumu, Kenya.

Unlike most quantitative studies that investigate decision-making on investing in sanitation, this study adopted a qualitative approach to investigate decision-making on shared sanitation in the informal settlements of Kisumu city, in Kenya. Using a grounded theory approach, landlords and tenants were interviewed to identify sanitation decisions, individuals involved in decision-making and factors influencing decision-making. The results indicate that the main sanitation decisions are on investment, emptying, repair and cleaning. Landlords make investment, emptying and repair decisions, while tenants make cleaning decisions. Absentee landlords are less involved in most decision-making compared to live-in landlords, who rarely consult tenants in decision-making. Tenants make decisions after consultations with a third party and often collectively with other tenants. Sanitation interventions in informal settlements should thus, target landlords and tenants, with investment efforts being directed at landlords and maintenance efforts at tenants

Estimating the Cost and Payment for Sanitation in the Informal Settlements of Kisumu, Kenya: A Cross Sectional Study.

Lack of sanitation facilities is a common occurrence in informal settlements that are common in most developing countries. One challenge with sanitation provision in these settlements is the cost and financing of sanitation. This study aimed at estimating the cost of sanitation, and investigating the social and economic dynamics within Kisumu's informal settlements that hinder provision and uptake of sanitation facilities. Primary data was collected from residents of the settlements, and using logistic and hedonic regression analysis, we identify characteristics of residents with sanitation facilities, and estimate the cost of sanitation as revealed in rental prices. Our study finds that sanitation constitutes approximately 54% of the rent paid in the settlements; and dynamics such as landlords and tenants preferences, and sharing of sanitation facilities influence provision and payment for sanitation. This study contributes to general development by estimating the cost of sanitation, and further identifies barriers and opportunities for improvement including the interplay between landlords and tenants. Provision of sanitation in informal settlements is intertwined in social and economic dynamics, and development approaches should target both landlords and tenants, while also engaging various stakeholders to work together to identify affordable and appropriate sanitation technologies

Understanding Living Conditions and Deprivation in Informal Settlements of Kisumu, Kenya

Informal settlements are a common occurrence in developing countries. Each settlement, however, has unique living conditions which require improvement efforts that are specifically tailored to the settlement. This study, carried out in Kisumu’s informal settlements, had two aims: to describe living conditions and to propose areas of improvement within the settlements. The study adopted two approaches: the living conditions framework and the multi-dimensional poverty index. Results indicate that deprivation is widespread at the individual and housing unit level, but the settlements are served with public services such as schools and health centres which residents can access. At the compound level, compounds lack infrastructural services such as water, sanitation and solid waste disposal, and where they are available, these services are shared. This study highlights the importance of basic service provision, upgrading of housing and supporting of existing income-generating opportunities within the settlements. Development efforts should involve all stakeholders, including landlords, tenants, community groups and governmental and non-governmental organisations

The Safe Start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: a study protocol for a cluster randomized controlled trial.

BACKGROUND: Symptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya. METHODS: This is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean. RESULTS: The primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination. CONCLUSION: To our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children. TRIAL REGISTRATION: The trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114)

Mapping social accountability actors and networks and their roles in water, sanitation and hygiene (WASH) in childcare centres within Nairobi’s informal settlements: A governance diaries approach

Introduction: Despite many institutions gaining access to improved water sanitation and hygiene (WASH) services, childcare centres in informal settlements have low access and poor condition of WASH services. It is imperative to understand how existing actors and social networks operate in the WASH sector in childcare centres in Nairobi’s informal settlements. Objective: To empirically map and understand how different actors within informal settlements influence the provision of adequate and quality water, sanitation and hygiene services within childcare centres in Nairobi’s informal settlements. Methods: This was a qualitative study. We conducted an ethnographic study using governance diaries with 24 participants from Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for 4 months, complemented with observations, reflections, participant diaries and informal discussions. We used a framework analysis which is partly deductive, informed by the governance framework and stakeholder framework. Results: Social accountability actors were individuals or groups involved in WASH service provision in childcare centres. The actors included both key actors (actors who are primary to meeting the day-to-day WASH service needs of children) and non-key actors (actors operating in the WASH sector but not always present for day-to-day provision in childcare centres). The key actors were unanimously identified as childcare centre owners/teachers and parents/guardians as they had a more direct role in the provision of WASH services in childcare centres. The actors had direct, possible or desired networks, with the direct networks portrayed more by the parents and childcare centre owners, whose roles included acting as a voice and responding to the WASH service needs of children as it relates to access and quality. Centre owners had more power/authority over WASH services for children in childcare centres than the parents. Key actors derived power by their discretion depending on whether a decision was beneficial to children or not. Lastly, the interest of key actors were diverse ranging from income generation, access to WASH services by children, compliance with government regulations, and promotion of child health, to the prevention of the spread of diseases. Conclusion: Our study highlights that parents and childcare owners play an important role in WASH service provision. While service providers and other players may be statutorily given primary responsibilities for WASH provision, and more visible in official standing, among study participants they are not seen as primary actors but secondary players with ancillary responsibilities. We conclude that WASH service provision in child care centres may be realised when key actors have a voice and work within networks to demand WASH services from desired networks including the government. We also conclude that developing more direct networks and converting desired and potential networks into direct networks in WASH service provision is critical for the success of WASH service delivery. Lastly, actors in WASH services in childcare centres may need to collaborate in identifying potential avenues for strengthening existing networks that enhance access and quality of WASH services in childcare centres

Designing a Food Hygiene Intervention in Low-Income, Peri-Urban Context of Kisumu, Kenya: Application of the Trials of Improved Practices Methodology.

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city's population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6-9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food

Bacteroides Microbial Source Tracking Markers Perform Poorly in Predicting Enterobacteriaceae and Enteric Pathogen Contamination of Cow Milk Products and Milk-Containing Infant Food

Consumption of microbiologically contaminated food is one of the leading causes of diarrheal diseases. Understanding the source of enteric pathogens in food is important to guide effective interventions. Enterobacteriaceae bacterial assays typically used to assess food safety do not shed light on the source. Source-specific Bacteroides microbial source tracking (MST) markers have been proposed as alternative indicators for water fecal contamination assessment but have not been evaluated as an alternative fecal indicator in animal-derived foods. This study tested various milk products collected from vendors in urban Kenyan communities and infant foods made with the milk (n = 394 pairs) using conventional culture methods and TaqMan qPCR for enteric pathogens and human and bovine-sourced MST markers. Detection profiles of various enteric pathogens and Bacteroides MST markers in milk products differed from that of milk-containing infant foods. MST markers were more frequently detected in infant food prepared by caregivers, indicating recent contamination events were more likely to occur during food preparation at home. However, Bacteroides MST markers had lower sensitivity in detecting enteric pathogens in food than traditional Enterobacteriaceae indicators. Bacteroides MST markers tested in this study were not associated with the detection of culturable Salmonella enterica and Shigella sonnei in milk products or milk-containing infant food. The findings show that while Bacteroides MST markers could provide valuable information about how foods become contaminated, they may not be suitable for predicting the origin of the enteric pathogen contamination sources

Designing a food hygiene intervention for children 6-9 months in an informal settlement in Kisumu, Kenya

Diarrhoea is a major public health issue in developing countries, especially among children as it contributes to growth faltering and malnutrition. Interventions targeting food hygiene are required to prevent the occurrence of diarrhea through contaminated food. The ‘Safe Start’ is a hygiene intervention study being implemented in informal settlements of Kisumu, and targeting early childhood exposure to enteric pathogens through contaminated food. Before introduction of the intervention, a formative study was conducted to identify target behaviours and design an intervention. This paper reports on the Trial of Improved Practices (TIPS) process, carried out during the formative phase and aimed at designing and testing candidate interventions before introduction on a larger scale. The process targeted four major behaviours, hygienic storage, handwashing with soap, hygienic feeding and reheating, and as a result, an intervention comprising education, environmental modification and motivational messaging was designed

Milk Product Safety and Household Food Hygiene Influence Bacterial Contamination of Infant Food in Peri-Urban Kenya.

BACKGROUND: Milk is a common infant food in peri-urban Kenya that can transmit diarrhea-causing enteric pathogens. Little is known about how contamination of milk at point of purchase and household handling of milk-based infant foods contribute to infant exposure to enteric pathogens. OBJECTIVE: To compare the prevalence and concentrations of bacterial indicator organisms and enteric pathogens in unpackaged, fresh pasteurized, and ultra-high temperature (UHT) treated milk at purchase and assess the influence of the type of milk used to prepare infant food on contamination of this food. METHODS: Paired samples of purchased milk and infant food prepared with this milk were obtained from 188 households in low-income neighborhoods in Kisumu, Kenya. Samples were cultured on selective media to isolate Salmonella enterica, Shigella spp., Klebsiella aerogenes, Proteus spp., and Escherichia coli, with pathogens validated by PCR. Probability of detection of these bacteria was compared by milk product treatment and packaging method, and between milk at point of purchase vs. food at point of infant consumption. RESULTS: Unpackaged milk was most contaminated at point of purchase, but bacterial contamination was also present in pasteurized and UHT milk at purchase. Presence of bacteria in UHT and fresh pasteurized milk at purchase predicted presence of the same bacteria type in infant food. Prevalence of bacterial contamination and concentration level for bacterial indicators generally increased between point of purchase and consumption in UHT and fresh pasteurized milk-based food but decreased in unpackaged milk-based food. Prevalence of the four fecal bacteria were similar in infant foods prepared with each type of milk. CONCLUSION: Both pre-market contamination and post-purchase handling influence the likelihood of infants ingesting foods contaminated by diarrheal pathogens