ASSESSMENT OF WATER, SANITATION AND HYGIENE IN PRIMARY SCHOOLS OF KAWANGWARE SLUMS

BY

CHALI T. NEGASSA MPH/113/01283

A RESEACH PROPOSAL SUBMITTED IN PARTIAL FULLFILLEMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH IN INTERNATIONAL HEALTH AND DEVELOPMENT MOUNT KENYA UNIVERSITY AUGUST 2014

DECLARATION

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

Student Signature ,,,,. Date ..Chali T. NegassaMPH/113/01283

Supervisors:

I/We confirm that the work reported in this thesis was carried out by the candidate under my/our supervision

1. Signature ..Date.... Dr. John G. Kariuki (Phd)

2. SignatureDate..

Ms. Monicah Njoroge

ABSTRACTEnsuring adequate water and sanitation facilities is a Millennium Development Goal that Kenya shares with other countries and access to safe water and adequate sanitation services is one of the most efficient ways of improving human health. School Water Sanitation and Hygiene (SWASH) envision a World where all children go to school and all schools provide a safe, healthy and comfortable environment where children grow, learn and thrive. SWASH implementation in schools is expected to contribute to the realization of childrens rights to survival and development. This study will assess SWASH in the primary schools in Kawangware slum and measure the parameters against the standards. In the study area, there is no clear and reliable information on the situation of SWASH and usability of the available facilities. The study area is classified as a slum area with scarcity of safe drinking water and many children suffer or are at risk of water borne diseases or water related diseases. A Baseline Survey (2010) revealed that about 63% of schools do not have safe water sources in their compounds. Though most of the schools had separate, gender specific latrines, only 20% meet the ratio of national pupil to toilet ratio standards for boys or girls. This will be a descriptive cross-sectional study and will use quantitative and qualitative methods to achieve its objectives. The study subjects will be public primary schools chosen at random, class 3 and 4 pupils (population as per Fisher formula) chosen at random and the head teachers of the participating schools. Statistical Package for Social Solutions (SPSS) statistical application software will be used. Descriptive statistics will be adopted using measures of central tendency at 95% confidence level. Data will be presented using frequency table and percentages. The results of the study will benefit the Stakeholders in Education sector, as well as the pupils in Kwangware slums.

TABLE OF CONTENTSDECLARATIONiiABSTRACTiiiTABLE OF CONTENTSivABBREVIATIONS/ ACRONYMSvOPERATIONAL TERMSviCHAPTER ONE: INTRODUCTION11.1Background to the study11.2Statement of the problem41.3Purpose of the study51.4Objectives of the Study51.5Research questions61.6HypothesisError! Bookmark not defined.1.7Justification and Significance of the Study61.7.1Justification61.7.2Significance81.8Delimitation and limitation of the study91.8.1Delimitation91.8.2Limitation101.9Theoretical framework101.10Conceptual framework10CHAPTER TWO: LITERATURE REVIEW122.1Availability and utilization of water122.2 Availability of adequacy sanitary facilities132.3 Hygiene practices among the primary school children15CHAPTER THREE: RESEARCH METHODOLOGY163.1Research Design163.3Target population163.4 Sampling techniques and sample size173.4.1 Sample size173.4.2 Sampling techniques183.5 Construction of research instruments193.6 Pre-testing /Pilot Study193.7 Recruitment and Training of Research Assistants193.8 Data collection methods and procedures203.9 Logistical and Ethical Considerations213.10 Data analysis techniques and procedures22REFERENCES23APPENDIX 1: SCHOOL QUESTIONNAIRE FORM28APPENDIX 2: PUPILS INTERVIEW QUESTIONNAIRE31APPENDIX 3: MAP OF KAWANGWARE WARD36APPENDIX 4: TIME FRAMEError! Bookmark not defined.APPENDIX 5: BUDGETError! Bookmark not defined.

ABBREVIATIONS/ ACRONYMS

MDG Millennium Development GoalsKNBS Kenya National Bureau of StatisticsUNICEF United Childrens Education FundWHOWorld Health OrganizationSWASH School, Water, Sanitation and Hygiene

SPSS Statistical Package for Social Solutions KNBS Kenya National Bureau of StatisticsNESHPNational Environment and Sanitation and Hygiene Policy WASH Water, sanitation and hygieneAPHRCAfrica Population and Health Research CenterMoEMinistry of EducationMoPHS Ministry of Public Health and SanitationUNUnited Nations

OPERATIONAL TERMS

Diarrhoea: is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual).Sanitation refers to means of preventing human contact from the hazards of waste to promote health and includes the provision of facilities and services for the safe disposal of human feaces and urine, but it can also be used to refer to the maintenance of hygienic conditions, through services such as garbage collection, including for menstrual hygiene protection materials, and wastewater disposal.Health promotion refers to the process of enabling people to increase control over the determinants of health and thereby improve their health.Hygiene is the method of using cleanliness as a method of preventing disease.Hygiene education refers to the provision of education and / or information to encourage people to maintain good hygiene and prevent hygiene related diseases.Hygiene facilities for schools refer to hand and body washing amenities, and sanitary bins in girls toilets and dustbins.Hygiene promotion refers to the planned, systematic attempt to enable people to take action to prevent or mitigate water, sanitation and hygiene related diseases.Intervention - the act or fact or a method of interfering with the outcome or course especially of a condition or process as to prevent harm or improve functioningPersonal hygiene refers to keeping the body clean to prevent disease.WASH facilities includes water supply facilities, latrines, hand-washing facilities, incinerators, refuse pits, and other waste collection and disposal facilitiesWater sources refers to spring water, tap water, shallow wells, rain water harvesting

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CHAPTER ONE: INTRODUCTION1.1 Background to the study

Water is a basic necessity of life. All living things man, animal and plants all depend on water for their life to continue. However, for millions of children, the water they drink can also be a source of persistent illness, leading to an early death. Globally, a child dies of diarrheal disease every 40 seconds WHO (2013). The share of this big number of deaths due to diarrhea is concentrated in Sub Saharan Africa where 1 in 8 children dies before reaching the age of 5 is about 17 times the average of developed countries where under five death rates is recorded to be 1 in 143 children UNICEF (2011). The same assessment data from 51 least developed countries and other low-income countries recorded that an average of 49% schools do not have access to safe water, and 55% schools do not have access to adequate sanitation facilitiesDiarrheal diseases cause an estimated 801,000 deaths per year, mostly among children under 5 years of age in developing world (Liu L, et al., 2010). A major contributing factor to this burden of disease is inadequate access to safe water and sanitation facilities. Access to safe drinking water and adequate sanitation services is vital to human health and is one of the most efficient ways of improving human health as shown by robust evidence of the impact of improvements in access to water; sanitation and hygiene (WASH) at home on the health of children under 5 years (Curtis & Cairncross 2003; Clasen et al. 2007& 2010). However gaining access to improved WASH is not simple as many people might think. It takes several years and billions of dollars to realize (Blanton E. et al., 2010). Currently over 780 million people in the world lack access to water supply, and approximately 2.5 billion lack access to sanitation facilities (WHO and UNICEF, 2012). SWASH envisages a world where all children attend school regularly and all schools provides safe, healthy and conducive environment where children develop, gain knowledge and thrive. It aims to ensure schools have access to adequate child friendly, gender and disability sensitive water and sanitation structures including hand washing facilities and hygiene education programme (www.unicef.org).

The Kenyan National School Health Policy goal and objectives as stated by GOK, (2009) is to enhance the quality of health in school communities by creating a healthy and child friendly environment for teaching and learning and its objectives include: Promotion of disease prevention and control as well as promotion of hygiene, sanitation and use of safe drinking water.The Kenya National Environment and Sanitation Policy (NESP) envisages that by 2015, every school will have hygienic toilets and hand washing facilities separate for boys and girls and attainment of this goal is expected to reduce the incidence of sanitation related diseases. The Policy further reveals that 80% of the hospital beds in Kenya are occupied by patients suffering from preventable diseases. About 50% of these illnesses are water, sanitation and hygiene related (MOH, 2007).The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are likely to provide water suitable for drinking include a piped source within the dwelling or plot, public tap, tube well or borehole, protected well or spring, and rainwater. According to the recent Kenyan Demographic and Health survey only 63 percent Kenyans get drinking water from improved source with clear inequality between urban and rural residents. Urban households approximated to 91 percent have access to improved drinking water sources as compared to 54 percent of their rural counterparts (KDHS, 2008/9). The Kenya demographic Health Survey (KDHS) 2008/9, did not capture data on Schools and hence a gap to be addressed by this study. Ensuring adequate sanitation facilities is a Millennium Development Goal (MDG) that Kenya shares with other countries. According to KDHS of 2008/9 a population accounting 30 percent urban and 20 percent rural residents have access to improved toilet facilities that is not shared with other households. In rural Kenya 47 percent households use the most common open pit latrine without a slab, while 52 percent of urban households shares toilet with other households. Overall, 12 percent of households have no toilet facility at all; they are almost exclusively rural, accounting for 16 percent of rural households (KDHS, 2008/9). The Kenya demographic Health Survey (KDHS) did not capture data on Schools water and sanitation, and hence a gap to be addressed by this study. The study area is Kawangware slums of Dagoretti Sub County in Nairobi County. It has hundreds of thousands of residents, many of whom are children. Water supplied by the city authority is not available every day and safe drinking water is expensive in Kawangware and most people there live on less than $1 USD a day (www.leeonenessfoundation.com).Kawangware slum is characterized with scarcity of safe drinking water, water borne diseases, respiratory pneumonia, malaria as well as an increase in cases of airborne diseases due to the poor drainage system. Safe drinking water is expensive to get. The cost of living in Kawangware is one of the highest in the world after Kibera and Mathare respectively (www.africalightchristian.org).

1.2 Statement of the problem

According to United Nations about 2200 children die daily from diarrhea globally as a result of poor sanitation (Liu L.et al., 2010). 400 million school-aged children a year are infected by intestinal worms, which, research shows, affects their cognitive learning abilities (www2.unicef.org). Approximately 80 percent of hospital attendance in Kenya is due to preventable diseases mainly due to lack of access to WASH facilities. According to the survey done by KNBS, 70 percent of urban areas in Kenya have access to safe drinking water regardless of their socio-economic status KNBS (2008). However, six years down the line, the coverage seems to have drastically decreased and currently only 59% of urban population have access to Improved adequate water supply while the coverage of sanitation is 32% for both urban and rural (WATER.ORG 2014; WASH plus/ USAID 2013). In Kenya, up to 50 per cent of the urban populations reside in slum environments where sanitation conditions are poor; on average, schools have only one latrine per 100 pupils compared with the recommended maximum of 40 pupils per latrine (webcache. googleusercontent.com /www.unicef.org/kenya). The case of SWASH in slum areas cannot be also different and there is no clear and reliable information on the situation of SWASH and utilization of the available facilities in the slum areas where basic social amenities are known to be scarce. 1.3 Purpose of the study

To assess water, sanitation and hygiene (WASH) interventions in schools in Kawangware slums and establish the magnitude of the problem and share the results for action. Access to safe water and adequate sanitation services is one of the most efficient ways of improving human health. WASH in schools envisions a World where all children go to school and all schools provide a safe, healthy and comfortable environment where children grow, learn and thrive and contribute to the realization of childrens rights to survival and development. The purpose of this study is to assess the extent of availability and utilization of WASH facilities in Kwangware primary schools in regard to SWASH standards besides the Kenyan Water and sanitation implementation plan. The study will give recommendation to the relevant Stakeholders and will also be a reference for the University and future studies.1.4 Objectives of the Study

The overall objectives of the study is to assess water, sanitation and hygiene (WASH) interventions in schools in Kawangware slums thereby to establish the level of SWASH coverage in regard to the international and local plans and strategies.

The specific objectives are:1.4.1 To assess the availability of adequate water for both drinking and hygiene in primary schools in Kawangware slums 1.4.2 To assess the availability of adequate sanitary facilities separate for boys and girls in Kwangware primary schools. 1.4.3 To assess the hygiene practices among the primary school children in Kawangware slums. 1.5 Research questions

1.5.1 What is the level of public primary schools in Kawangware slums access to safe drinking water?1.5.2 What is the extent at which Public Primary schools in Kawangware slums have adequate sanitary facilities?1.5.3 Do the Pupils in Primary Schools in Kawangware wash hands with soap at critical times? 1.6 Justification and Significance of the Study

1.6.1 Justification

The success of any health policy or health care intervention depends upon a correct understanding of socio-economic, environmental and cultural factors which determine the occurrence of diseases and deaths. In SWASH interventions, the success is determined by how good the school environment ensure social, cultural and emotional wellbeing of the young ones through providing basic water supply, sanitation facilities and proper hygiene awareness in order to enable and promote a healthy child friendly school. The Baseline Survey done by Ministry of Education (MOE) in 2010 revealed that, 37.3 percent primary schools had safe drinking water sources in their compound or within 200 meters from the school yard, 86.9 percent schools had child friendly separate latrines for girls, boys and school personnel although, less than a quarter (less than 25%) of them complied with the countries standard (UN, 2012) . This non compliance to the standard indicates that the facilities may be available in some of the schools but falls short of the standard when the numbers of facilities are checked against student ratio.

In the other study conducted by the scholars of African Population and Health Research Center (APHRC) in 22 primary schools in Korogocho and Viwandani slums of Nairobi, 270 pupils relying on one tap against the recommended standard of 50 students per one tap. Toilet ratio is also found to be at 1:84 for both girls and boys as opposed to the recommended ratio set by Kenyas Ministry of Education (MoE) of 25 girls and 30 boys per one toilet. 89% of the students wash their hands without soap and 40% do not wash their hands at all when they are out of school. Only three schools reported to occasionally providing soap for hand washing, although not verified because the soap was not available at the time of the study visits (APHRC, 2008).

The recent studies carried out in three primary schools in Kibera Slums, had appeared to be highly varying regarding student toilet ratio. In this study the average ratio of toilet for both boys and girls are 1:25, 1:33, and 1:103 for Premier Acadamy, Toi Primary, and Boon House Primary schools respectively. Concerning hand washing , Bon house school scored the highest with 75% of total children observed washing hands with soap, where as Premier Academy and Toi Primary recorded 65% and 38% respectilely (Rufus Eshuchi, 2013). However, the soaps used in these schools were provided by the researcher for the study purpose.The different studies carried out in Kenya Primary schools, mostly were done on WASH impact, Menstrual hygiene management (MHM), Hand washing practices, Retention of hygiene education owing big variation in their results indicating shortage of reliable data regarding the current status of national SWASH interventions in Kenya (Washmapping.com & Alexander, K.T. et al., 2014.).

Therefore, this study aspires to fill the gaps in knowledge by conducting an assessment of water, sanitation and hygiene (WASH) interventions in schools in Kawangware slums thereby establishing the level of achievements in regard to the international and local plans and strategies. The assessment will also help to come up with documented evidence regarding the level of access to SWASH facilities and proper utilization of SWASH services. This will help to make available the necessary information and documented evidence for Kwangware and other similar slum in the country.1.6.2 Significance

The assessment of SWASH is important in the sense that water is important for the welfare of the children, sanitation is for the prevention of the diseases and good hygiene to create awareness through provision of health related information. This study is critical for Kawangware primary schools as it is situated in a poor and marginalized area where similar studies have not been conducted.The results of the study will be used by both primary stakeholders such as MOE, MOH, and secondary stakeholders such as national and international NGOs, civil societies, and international organizations. The findings will in particular benefit Stakeholders in Education sector and the pupils in Kawangware slums. 1.7 Limitation and Delimitation of the study1.7.1 Limitations of the studyStudies have various limitations of their own (Leedy & Ormrod, 2005), or they have potential weaknesses or problems with the study identified by the researcher (Creswell, 2005:198).This study will be conducted in public government schools situated in Kawangware slums where basic public services are believed to be scarce. Hence, the result will be limited to slums of similar nature and will not possibly represent the other WASH resource and facilities scarce communities in the urban or rural areas of the Republic of Kenya. The study will also be limited to, Government of Kenya Public Primary Schools partly due to time and financial constraints and will not sample public private/ mission schools and hence the result will be indicative of the current coverage status of public primary schools and may not truly represent others. Moreover, the respondent to the study may be possibly mentored by the school teachers to answer the questionnaires in a certain ways that may jeopardizes the result and hence the study result might not, therefore, be truly representative of the schools.

1.7.2 Delimitations of the study

Delimitations is what the researcher is not going to do (Leedy & Ormrod, 2005). This study will be conducted in all randomly selected Public Primary Schools in Kawangware slums. It is delimited to only those Public Primary Schools in Kawangware slums and not other areas. Generalization to other areas other than from public primary schools in similarly known slums such as Kibira, Mathare, Korogocho.. may not be warranted. Kawangware is selected as the study site for the area is known to the researcher and it is also a slum area where basic services are believed to be scarce. The study will cover three key areas of the WASH: access to Water, Sanitation and Hygiene Promotion. In the area of knowledge attitude and practice on hygiene, the study will purposefully interview systematically selected pupils using the class register from standard 3 and 4 of sampled primary schools. The results of this study will be limited for generalization except for areas like Mathare, Kibera, korgocho.. that are similarly classified as slums. 1.8 Theoretical frameworkThe overall objective of UNICEF and other Partners in the area of water, sanitation and hygiene (WASH) is to contribute to the realization of childrens rights to survival and development through promotion of the sector and support to national programmers that increase access to, and use of, safe water and basic sanitation services, and promote improved hygiene in an equitable and sustainable manner. The sustainability of WASH programs has three pillars for enhanced child survival and development. These are Availability of WASH services, Enabling environment and behavioral change. 1.9 Conceptual frameworkAddressing a childs right to health and education through the provision of WASH ensures that all children have access to high quality water and sanitation services at school, and the benefit of hygiene education. School-based WASH activities represent an opportunity to directly address a childs right to both education and health since access to safe drinking water and adequate sanitation services is vital to human health and has benefits as shown in conceptual framework in figure 1, if all schools provide WASH interventions. INDEPENDENT VARIABLE ENABLING VARIABLE DEPENDENT VARIABLE

Availability of adequate and improved water supply throughout school calendar.

Improved healthBehavioral change

Healthy and child friendly school with reduced absenteeismProper, equitable use and management of facilities, good personal and environmental Hygiene Practice .in the area.Availability of adequate, improved sanitation facilities separate for boys and girls.

Availability of sufficient SWASH awareness education and materials.

Figure 1: Researchers conceptual framework

CHAPTER TWO: LITERATURE REVIEW2.1Availability and utilization of water

Globally statistics show that school water coverage has increased from 63 percent in 2008 to 70 percent in 2010 (UNICEF, 2010a). The WASH intervention in school has been documented to have positive evidence of the health of the pupils, including psychosocial and educational benefits. For example, evidence shows that school-based WASH programs reduce absence and parasitic infection (Bowen, Ma et al., 2007; Freeman, Clasen et al., 2011; Freeman, Greene et al., 2011).In low income countries data on access to water and sanitation in schools is scarce. An evaluation by UNICEF found that in schools in 49 low-income countries, only 51% had access to adequate water and 45% had adequate sanitation facilities (UNICEF, 2012).WASH in Africa has made different levels of progress towards the Millennium Development Goal. Northern Africa and Sub-Saharan Africa recorded completely different levels of achievements. North Africa has 92% coverage and is on track to meet its 94% target before 2015. However, Sub-Saharan Africa is in general off track at 61% water coverage and with the current pace cannot meet the 75% target for the region (UN 2012). An analysis of data from 35 countries in sub-Saharan Africa (representing 84% of the regions population) shows significant differences between the poorest and richest fifths of the population in both rural and urban areas. Over 90% of the richest quintile in urban areas use improved water sources, and over 60% have piped water on the premises. In rural areas, piped-in water is non-existent in the poorest 40% of households, and less than half of the population use any form of improved source of water (UN 2012). Kenyas national environmental sanitation and hygiene policy (NESHP) in its goal number ii indicated that by 2015, every school, institution, household, market and other public place will have access to, and make use of hygienic, affordable, functional, and sustainable toilet and washing facilities (NESHP, 2007).

In Kenya, the recent studies carried out in three primary schools in Kibera Slums, had appeared to be highly varying regarding student toilet ratio. In this study the average ratio of toilet for both boys and girls are 1:25, 1:33, and 1:103 for Premier Acadamy, Toi Primary, and Boon House Primary schools respectively. Concerning hand washing , Bon house school scored the highest with 75% of total children observed washing hands with soap, where as Premier Academy and Toi Primary recorded 65% and 38% respectilely (Rufus Eshuchi, 2013). However, the soap used in these schools were provided by the researcher for the study purpose.Treating water at the point of use and hygienic storage of drinking water reduces the risk of contracting diarrhea by 30-40% (USAID 2004)2.2 Availability of adequate sanitary facilities Globally it is documented that school sanitation coverage has increased from 59 percent in 2008 to 67 percent in 2010 (UNICEF, 2010a).The study done by UNICEF in three districts in Mozambique, showed that there are still a lot to do in regard to WASH at all levels. Fewer latrines have been available in schools as compared to number of pupil. Shortage of water supply facilities and classrooms for the ever increasing number of pupil are significant issues particularly in populated schools. Moreover, the study also indicated maintenances of facilities as another key issue that needs to be given attention together with capacity building (UNICEF 2009)

Ensuring adequate sanitation facilities is a Millennium Development Goal that Kenya shares with other countries. According to the KNBS of 2008/9 less than one-quarter of households use an improved toilet facility that is not shared with other households. Urban households are only slightly more likely than rural households to have an improved toilet facility (30 percent and 20 percent, respectively). The most common type of toilet facility in rural areas is an open pit latrine or one without a slab (47 percent of rural households), while in urban areas toilet facilities are mainly shared with other households (52 percent). Overall, 12 percent of households have no toilet facility at all; they are almost exclusively rural, accounting for 16 percent of rural households (KNBS, 2008/9).In a study on the impact of WASH interventions in Nyanza, there was a 58% reduction in the odds of absence for girls concluding that the improvement in the availability of SWASH can improve school attendance for girls (Matthew C. Freeman et al., 2011). In a Baseline Survey done in 2010 in 22 districts supported by Unicef SWASH programme in 343 sampled schools, found out that, about 63% of schools did not have safe water sources in their compounds. Though most of the schools had separate, gender specific latrines, only 20% meet the ratio of national pupil to toilet ratio standards for boys or girls (Baseline Survey 2010).Safe excreta disposal by using improved latrines can reduce the risk of diarrheal by 32% (Fewtrell, 2005). Moreover, SWASH intervention is found to promote girls attendance and reduces absentiseem by 39% particularly when the school toilet ensures privacy, cleanliness, and safety at the time of menstruation (UNICEF, 2010).

2.3 Hygiene practices among the primary school children Blanton and others in their studies on hand washing programs show that children are good agents of WASH Programs as they share knowledge at home (Blanton et al., 2010; Bowen et al., 2010). It is believed that they take home the knowledge that they gain from SWASH program and share with their parents and family members as well as with the community. Available evidence also show that School WASH can reduce absenteeism (particularly for girls), reduce helminthes infections and change household hygiene behaviors (Bowen, Ma et al., 2007; Freeman, Clasen et al., 2011; Freeman, Greene et al., 2011).

Studies confirmed that proper hand washing with soap have proofed to reduce the risk of diarrhea infection by 42-44% (Curtis & Carnicross, 2003)

CHAPTER THREE: RESEARCH METHODOLOGY

3.1Research DesignThis is a descriptive cross-sectional study. Quantitative and qualitative methods will be used to collect data in order to achieve the aim of the study. Semi structured questionnaire and key informant interviews will be administered to the pupils and head teachers respectively.

3.2 Location of the study Kawangware division is one of the two divisions in the sub county of Dagoretti under Nairobi county in Kenya. It is located about 15 kilometers west of the city centre of Nairobi. It is Kenyas second largest slum after Kibera, and the fourth largest in Africa with a population of over 300,000 people. It is one of the fastest growing and poorest slums in the city (KNBS., 2009).3.3Target populationThe target populations for this study will be sampled schools from Kenya public Primary Schools in the division of Kawangware slums in Dagoretti Sub County. 10 pupils from each class 3 and 4 will be systematically selected as shown in sampling frame or techniques. The head teacher or health teacher will be the key informants from each school and hence will be responding to various questions regarding major WASH facilities in their respective school. The questions include some vital demographic questions, availability and status of the facilities verses utilities as well as mechanisms of managing the facilities that will be verified together with the investigator through observation as indicated in Appendix I: school questionnaire form.3.4 Sampling techniques and sample size 3.4.1 Sample size Since there was no clear information on the coverage of Schools by SWASH programs and available information are contradicting and great variability has been observed, the study will use 50% proportion as the coverage of the SWASH intervention (Fisher et al, 1983). The Dagoretti sub county has two divisions, namely Kwangware and Waithaka divisions. According to KNBS 2009 census, the total population of the Dagoretti sub county is 329,577 and the total number of primary school age children 6-14 years are 53,890. Data obtained from Dagoretti sub county education office reveals that 20,851 pupils have been enrolled in the 24 public primary schools in the sub county whereas other significant number of students go the various formal and informal private schools. The population of primary school potential age group (6-14 years) in Kawangware division is assumed to be at least about half the 53,890 in the two divisions of the Dagoretti sub county. This still produces a sampling population of approximately 27,000potential age group. However, the actual student enrollments at the beginning of 2014 is 20,851. If we assume that the pupils enrolled in Kwangware division is about half, the sample population can be approximated to 10,500 which is still over 10,000 children. The desired sample size is therefore obtained by applying Fishers formula for sample size determination as follows: n 2 1- (1-p)2 ____________ d2Where;n = sample size 1- (standard normal deviation at 95% confidence level) = 1.96d (Absolute precision) = 5%p (SWASH coverage) = 50%n = (1.96)2 (0.5) (1- 0.5) (0.05)2n = (1.96)2 (1- 0.5)2 = 384 (0.05)2

Therefore number of respondents will be 384.For smaller sample such as school in this case, to arrive at the sample size of the schools to be assessed out of the 24 school available in Kawangware Division:

nf = n/(1+n/N)nf = n/ (1+n/N) = 385/ (1+384/24) =21 schools. Where: nf = desired sample size when target population is less than 10,000n= sample size when target population is greater than 10,000N = an estimate of the target population (24 primary schools) However, to harmonize the Kenyan comprehensive school health implementation handbook and the fishers formula of sample size determination, the researcher would like to do the studies in 20 primary schools where in each school 20 students will be interviewed from standard 3 and 4.

3.4.2 Sampling techniquesAll 24 Public primary schools will be listed and given numbers that will be prepared in a form of raffle as follows: 24 small pieces equal size paper will each have a number constituting each of the school ( i.e. 1 to 24) rolled and put into deep container and properly mixed and 20 schools will be randomly be picked for the assessment or the four schools to be excluded will be picked from the 24 raffles prepared representing each school, whichever method is easier. The Key Informant to be interviewed will be the Head Teachers (or the Health Teacher) of the respective sampled primary schools. The pupils to be interviewed from the sampled primary schools will be those from class 3 and 4 using the GOK Kenya Comprehensive School Health Implementation Handbook (CSHIH). The Handbook recommends interviewing 20 children 10 children from each class 3 and 4, through random sampling using registers eg every 5th child.3.5 Construction of research instrumentsData collection tools will be constructed to collect both quantitative and qualitative data. Key informant interview schedule Appendix II (School Form Interview), will be constructed to collect information from the head teacher or health teacher on demographic data, number and status of available WASH facilities, management of the facilities, availability of utilities. The questionnaires are filled (completed) by the through observation and response obtained from the respondents. Information will also be collected from the students using Appendix III (Pupils interview questionnaire form) that deals with the type of WASH facilities they have at home and detailed questions related to the knowledge, attitude and practice of hygiene/health education. Questionnaires in Appendix II are divided into parts which are variables. Part I,II,III,IV and V. This parts are variables namely: I) Demographic Information, II) Availability and Access to safe drinking water, III) availability and access to sanitation facilities, IV) Provision and access to hand washing facilities and V) provision of hygiene education. 3.6 Pre-testing /Pilot study

All the data collection tools will be pretested and realigned for accuracy. The tools will be pretested in one GOK Primary School chosen at random from Kibera slums or Mathare slums which are also classified as slums.

3.7 Recruitment and Training of Research Assistants

A total of 4 research assistants will be recruited to collect data (2 males and 2 females) for gender balancing. They should have completed secondary education and this will help in understanding the context of the proposed study. The research assistants will be given adequate training on data collection, interview techniques and ethical issues needed in data collection. To ensure standardized performance and achieve the required reliability of the study, the interviewers will be paired off to practice out interviewing among themselves till the required objectivity is reached.

3.8 Data collection methods and procedures

After clearance is granted by the university, the Ministry of Education Science and Technology and other concerned bodies, the researcher and the research assistants will first visit Dagoretti Sub County headquarters (i.e. The Sub County head education office) and meets with the education managers of sub-County as an administrative and protocol matters before collecting data. The researcher will administer the key informant interview schedule using the School Form (Appendix 1) to the Head Teachers of each of the randomly selected GOK Public Primary School. The head teacher or the health teachers in the selected schools are supposed to answer the majority of questions in appendix 1 apart from those questionnaires to be filled through observation. The two research assistants will split and one will administer the pupil questionnaire (Appendix 2) for the class 3 and the other for class 4 pupils in each school until all sampled schools are visited. Before interviewing the pupils, the class teachers of class 3 and 4 will explain the purpose of the study and will ask the pupils to remain in the class until the selection process is over using the class record. The sample selection will be done by counting from number one on the register and then skipping pattern will be applied every 3 or 5 pupil depending on the population of the class until 10 pupils are selected to participate in the study. The pupils will then be interviewed separately.

3.9 Logistical and Ethical Considerations

Permission to conduct this study will be obtained from the Mount Kenya University, the Ministry of Education, Science and Technology, Nairobi City Education Office and Dagoretti Sub County Education Office. Confidentiality of the names of respondents will be guaranteed. Respondents will be given assurance that they will suffer no harm as a result of the study as well as freedom to withdraw whenever deemed necessary. Informed consent will be sought from the head teacher or health teacher both for themselves and the pupils participation in the assessment. Upon sufficient explanation regarding the study, the purpose and objectives of the research, the head teacher will voluntarily agree to respond to Appendix II of the research questionnaire and observation form. Moreover, the head teacher/ principal or the representative will be requested to sign consent to authorize the participation of pupils as respondents on behalf of parent/guardian for the fact that in Kenya it is a common belief that school children are under the protection of teachers, particularly, the head teacher/principal. Voluntary consent will also be sought from pupils themselves in order to respond to the research questionnaires. All information obtained during this work will be handled to preserve the confidentiality of the subjects, but the names of Schools will be listed generally.

In Kenya, it's customary that teachers sign health club activities, projects and field trips consent forms on behalf of parent/guardians. Kenyan Parents regard and assign the school a high level of guardianship and confident on the capacity of teachers to assess the benefits of pupils participation in selected school activities. This is mainly because of the adult literacy level that is believed to have an effect on the understanding of most parents. According to the 2000 UNISCO assessment of education and average years of schooling of adults, Kenya recorded an average of 4.2 years of formal schooling in contrast of the lower 0.8 and the highest 12 years of schooling recorded in Guinea-Bissau and the USA respectively (http://www.nationmaster.com/country-info/stats/Education/Average-years-of-schooling-of-adults). It is due to this limitation in education level, schools normally use the responsibilities delegated to the teachers by parents/guardians committee to evaluate the right and benefit of their minor children and consent on their behalf. As a result, schools do not have a custom of sending parents/guardians to sign for consent to undertake certain activities. Therefore, for this particular study, the researcher believed it was most appropriate to follow the same trend that the pupil and their teachers/principals sign the consent form rather than the parents/guardian. 3.10 Data analysis techniques and procedures

Data obtained from all forms of interview and checklist will be checked at the end of each day by the researcher to ensure they are correctly completed. Data will then be cleaned, coded and entered into the computer for analysis using SPSS version 20.0. Descriptive statistics will be adopted using measures of central tendency at 95% confidence level. Data will be presented using frequency table and percentages. Analysis of contingency tables will be done and chi square statistic will be used to test for association between variables and level of significance.

3.11 REFERENCES

Alexander, K.T.; Oduor, C.; Nuthatch, E.; Laserson, K.F.; Amek, N.; Eleveld, A.; Mason, L.; Rheingans, R.; Beynon, C.; Mohammed, A.; Ombok, M.; Obor, D.; Odhiambo, F.; Quirk, R.; Phillips-Howard, P.A. Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls? Water 2014, 6, 1453-1466)

APHRC (2008) African Population and Health Research Working Paper 42, 2008: Determining Appropriate Entry Point for Health Promoting Schools Intervention in Nairobis Informal Settlements. Osnat Keidar, Elliot M. Berry, Alex C. Ezeh, Milka Donchin. Available at: http://urbanhealthupdates.wordpress.com/2009/07/09/kenya-survey-of-school-hygiene-in-nairobis-informal-settlements/,, accessed Oct 2014.

Baseline (Survey 2010). www.washinschoolsmapping.com/projects/Kenya.html). Retrieved on 02/07/2014.

Blanton, E., Ombeki S., Oluoch G. O., Mwaki A., Wannemuehler K., Quick R. (2010). Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and householdsNyanza Province, Western Kenya, 2007. American Journal of Tropical Medicine and Hygiene 82 (4): 664-71.

Bowen A., Ma, H., Ou, J., Billhimer, W. Long, T. Et al. (2007). A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. American Journal of Tropical Medicine and Hygiene 76 (6): 1166-1173.

Clasen TF, Bostoen K, Schmidt WP et al. (2010) Interventions to improve the disposal of human excreta for preventing diarrhea. The Cochrane database of systematic reviews 6, CD007180.

Creswell, J., 2005. Educational research: Planning, conducting, and evaluating quantitative and qualitative research (2nd Ed.). Upper Saddle River, NJ: Pearson.

Curtis V & Cairncross S (2003) Effect of washing hands with soap on diarrhea risk in the community: a systematic review. The Lancet Infectious Diseases 3, 275281.

Elizabeth Blanton, Ombeki S, Oluoch G, Mwaki A, Wannemuehler K & Quick R (2010) Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and householdsNyanza Province, Western Kenya, 2007. American Journal of Tropical Medicine and Hygiene 82,664671.

Fisher, R. A. 1983. Statistical Methods for Research Workers. 30th edition. Hafner Publishing Company. New York. USA.

Freeman, M., Clasen T., Brooker S., Akoko D., Brumback B., Rheingans R. Et al. (2011). The impact of a school based hygiene, water treatment, and sanitation intervention on re-infection with soil transmitted helminths in western Kenya: a cluster-randomized trial. Paper presented at the Water and Health Conference: Where Science Meets Policy. Chapel Hill, NC.

Freeman, M., Greene, L., Driebalbis R., Saboori S., Muga R. et al. (2011). Assessing the impact of a school-based water treatment, hygiene, and sanitation program on pupil absence in Nyanza Province, Kenya: A cluster randomized trial. Tropical Medicine and International Health. DOI: 10.1111/j. 1365-3156.2011.02927. x. [E-pub ahead of print].

Government of Kenya (2009) National School Health policy Ministry of Public Health and Sanitation and Ministry of Education

Government of Kenya (GOK). Kenya Comprehensive School Health Implementation Handbook. Page 23-24.

http://webcache.googleusercontent.com/search?q=cache:x593bBFn0kMJ:www.unicef.org/kenya/wes.html+&cd=1&hl=en&ct=clnk. Accessed on August 2014.

http://www.unicef.org/wash/index_43084.html. Retrieved on 29/07/2014. http://www2.unicef.org:60090/wash/index_schools.html. Accessed on 01/02/2014Kenya National bureau of statistics (KNBS) 2008. Well being in Kenya. A socioeconomic profile June 2010. Kenya National bureau of statistics (KNBS) 2009, Kenya Demographic and Health Survey, and ICF Macro.2010. 2008-09: Calverton, Maryland, USA: KNBS and ICF Macro.

Leedy, P., &Ormrod, J., 2005. Practical research: Planning and design (8th Ed.). Upper Saddle River, NJ: Prentice Hall (http://iisit.org/Vol6/IISITv6p323-337Ellis663.pdf), Accessed on 05 Sep, 2014. Liu L,Johnson HL, Cousins S,Perin J et al.,Child Health Epidemiology Reference Group of WHO and UNICEF. Global and regional, and national causes of child mortality; an updated systematic analysis for 2010 with time trends since 2000. Lancet.2012 Jun 9;379 (9832): 2151-61.

Matthew C. Freeman, Hubert Department of Global Health, Center for Global Safe Water, Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE, CNR 2027, Atlanta, GA 30322, USA. E-mail: mcfreem@emory.edu Assessing the impact of a school-based WT, hygiene and sanitation program

MOH (2007). National Environment and Sanitation Policy, July 2007, Nairobi p6.Rufus C. E. Eshuchi (2013). Promoting hand washing with soap behavior in Kenyan schools: learning from puppetry trials among primary school children in Kenya (PhD thesis report).

The National Environmental Sanitation and Hygiene Policy (NESHP, 2007). Ministry of Health, Division of Environmental Health, July 2007.UN (2012). The Millennium Development Goals Report 2012. International Decade for Action Water For Life 2005-2015. Data retrieved from: http://www.un.org/millenniumgoals/pdf/MDG%20Report%202012.pdf. On 09/02/2014.UN Inter-agency Group for Child Mortality Estimation, report 2011

UNICEF (2010a). WASH Annual Report. Author: New York.

UNICEF (2011). Levels & Trends in Child Mortality: Estimates Developed by the

UNICEF 2009. Child Friendly schools initiative in Mozambique, Annual field assessment report, February 2009.UNICEF. (2010). Raising Clean Hands: Advancing Learning, Health and Participation through WASH in Schools. New York.UNICEF 2012. Raising Even More Clean Hands. New York. Available at: http://www.unicef.org/wash/schools/files/Raising_Even_More_Clean_Hands_Web_17_October_2012%281%29.pdf. Accessed in august 2014.

UNICEF/WHO (JMP 2012). Progress on drinking water and sanitation, update 2012. http://www.unicef.org/media/files/JMPreport2012.pdf. Accessed on 21 July 2014.Washplus/USAID2013.http://www.washplus.org/sites/default/files/wash_nutrition 2013.pdf. www.unicef.Org/Kenya WHO (2013). Media Centre, diarrheal disease Fact sheet N330 April 2013. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/. Accesses on July 2014.

www.africalightchristian.org/index.php. Retrievedon06/08/2014. www.leeonenessfoundation.com/projects/kawangware). Retrieved on 03/08/2014.

Fewtrell, L. K. (2005). Water, Sanitation and Hygiene Intervention to reduce diarrhea in less developed countries: A systematic review and Meta-analysis. Lancet Infectious diseases.

APPENDIX I

Letter of Introduction

Dear Sir/Madam,

My Name is Chali Negassa, I am a Masters of Public Health student at the Mount Kenya University undertaking research on ASSESSEMMENT OF SCHOOL WATER, SANITATION AND HYGIENE IN PRIMARY SCHOOLS IN KAWANGWARE SLUMS. It is my humble request that you assist me by filling the questionnaire while responding to the questions as correctly and honestly as possible. Be assured that your identity and responses will be treated with utmost confidentiality.

Thank you in advance for your willingness to participate in this important exercise.

Yours Faithfully

Chali T. Negassa

APPENDIX I: SCHOOL QUESTIONNAIRE FORM

Part I: Demographic information

(The interviewee is the head teacher or health teachers)

1. Form serial No:_________________________2. Division: _________________________________.3. School Name:_____________________________________4. No of male staff_______5. No of female staff_______6. Total no of staff_________7. No. Of boys__________ 8. No of girls____________ 9. Total No of pupils________

Part II: Availability and Access to safe drinking water

(OBSERVATION CHECKLIST: to be done by the interviewer):

10. What are the sources of drinking water for the children while in school?1. Brought from home2. Tap water at school3. From borehole at the school4. From a dug well at the school5. Other (specify)Part III: Availability and access to sanitation facilities

11. What type of sanitary facility does the school have? (Ask and observe)1. Flush toilet2. VIP latrine3. Ordinary pit latrine4. Other (Specify)..12. If a pit latrine, what kind of floor does it have? 1. Cemented2. Earth (soil)3. Wooden4. Other (pecify).13. What is the general cleanliness of the flush toilet facility (ies)? SexNo. Of toiletsNo. CleanNo. DirtyAdequateNot adequate

Boys

Girls

Total No.

Criteria: Dirty- If not flashed, blocked, presence of fecal matter outside the toilet

14. What is the general cleanliness of the pit latrine facility (ies)?Sex#of pit latrines# Clean# DirtyAdequateNot adequate

Boys

Girls

Total No.

Criteria: Dirty- If presence of dirty matter on the floor, on the wall or outside the pit latrine.

19. Who cleans the toilets?1. School children2. School workers3. Other (specify).20. How often are the toilets cleaned?1. Once a day2. Twice a day3. Once a week4. Twice a week5. Other (specify)

Part IV: Provision and access to hand washing facilities

15. Is there any hand washing facility (ies) near the toilet(s)? 1. Yes2. No16. If yes to question 15 above, what type of hand washing facility? And how many? 1. Tap water_____________2. Hand washing basin_________3. Leaky tins___________4. Others:Specify_______________________________________________17. Observe availability of water (in HW Facilities)1. Available2. Not available

18. Is there any soap for washing hands?1. Yes2. NoPart V: Provision of hygiene education and Environmental sanitation

23. Do the school provide Hygiene /health education1. Yes2. No24. How often do you give hygiene education1. Every Day2. Once a week3. Once a month4. Other (Specify)__________________________________ 21. Nature of school playground (observation)1. Earth/ dusty ground2. Marram covered ground3. Grass covered ground4. Other form of cover Specify________________________________________22. How is the solid waste (from school) disposed off? (+observation)1. Composite pit2. Open burning3. Burying4. Indiscriminate dumping (open dumping)5. Others (specify) __________________________23. Do you have specific school cleaning day?1. Yes2. No24. How often is the school compound cleaned?1. Every week2. Every two weeks3. Every month4. Other (Specify)____________________________

Name of Interviewer: _________________________________

Signature:_________________ Date:______________________APPENDIX II: PUPILS INTERVIEW QUESTIONNAIRE

Part II: Availability and Access to safe drinking water

1. What is the main source of water at home?1. River2. Spring3. Piped water4. Bore hall// well5. Vendors6. Others(specify) __________________________2. Do you do anything to treat or make water safe for drinking?5. Yes6. No3. If yes, what do you do to make water safe for drinking?1. Boil always2. Boil sometimes3. Filter4. Add chemicals (disinfect) such as water guard5. Others (specify)..

Part III: Availability and access to sanitation facilities

4. Do your family have a latrine/ toilet at home?1. Yes2. No5. If yes, what type?1. Family pit latrine2. VIP latrine3. Water closets (WC)4. Other (specify)____________________________6. Do you share your toilet with others?1. Yes2. No

Part IV: Provision and access to hand washing facilities7. Is there hand washing facility in your school?1. Yes2. No8.If the answer to the above question is yes, do you use the facilities?1. Yes2. No

9. If No, why?1. Due to long queue at the facilities2. Too high for young children3. Mostly no water in the facilities4. The area is muddy, dirty and not convenient.5. Other reasons (Specify)____________________________Part IV: Hygiene /health education absorption and practice

10. When do you wash your hands?1. ____________________2. ____________________3. _____________________4. ______________________11. Why do you wash your hands before eating?

1. To feel good by being clean2. Preventing diseases3. Other (specify)..12. Do you use soap when washing hands in school?1. Yes2. No13. If yes, check availability of soap, ash.. at the HWfacilities1. Available 2. Not available14 .Should fruits be washed?3. Yes4. No15. Do you wash fruits before eating?1. Yes2. No16. If no to question 9 above, why not?1. Lack of water2. No need to wash3. Other (specify)_______________________17. Have you been sick in the last two weeks?1. Yes2. No18. If yes, what were you suffering from?1. Diarrhea2. Cough 3. Stomach aches4. Headache5. Other (specify)____________________________19. Did you go for treatment?1. Yes 2. No20. If no, why?1. I was not too sick2. I bought medicine3. Lack of money4. Other (specify)____________________________21. Do you wear shoes while in school? (Observe)1. Yes 2. No22. How many times do you brush your teeth in a day?1. Once 2. Twice3. Not even daily

23. How many times in a day do you take a bath / shower?1. Once a day2. Twice a day3. Every other day4. Twice a week5. Once a week

24. Do you wear clean clothes? (Observe)1. Yes 2. No25. Do you cut and clean your fingernails? (Observation)1. Yes 2. No26. Is your hair well kept? (Observation)1. Yes 2. No27. Mention at least two diseases which can be avoided by using latrines?1. __________________________2. __________________________28. Mention at least one parasites which can be avoided by wearing shoes?

1. __________________________2. __________________________

Name of the interviewer ________________________________________________Signature: _________________________________________________Date:________________________________________________

Note:At least two diseases: Diarrhea, cholera, Typhoid, Bilhazia, DysentryAt least two parasites: Jiggers, Hookworm

APPENDIX 3: MAP OF KAWANGWARE WARD

Appendix 4: Time Frame

Activity DECEMBERJANUARYFEBURARYMARCHAPRIL

Proposal approval

Recruitment of research assistants & training

Pretesting of data collection tools (pilot study)

Actual data collection from schools

Data entry and analysis

Report writing and submission of 1st draft

Submission of 2nd draft report

Defense of the thesis report

Production of final revised copies

Appendix 5: BudgetItem DescriptionQuantitycomputationTotal Amount

Research assistants4 NO4x1000/=x 5days20,000

Fuel500 litres500x112/=56,000

Stationery10 reams10x500/=5000

Typesetting100 pages100x40/=4000

Printing2000 pages2000x10/=20,000

Binding10 copies10x500/=5000

GRAND TOTALKSHS.129,900