Theme: From Evidence to Action: Lasting Health Change for Africa

 

Title: Behavioral changes in trachoma control among pastoral communities of Samburu, Kenya

Principal Investigator: Solomon Mwaniki - AMREF Kenya

Co- Investigators: Francis Dikir, Chitiavi Juma, Christian Ochieng (AMREF Kenya)

Amref Health Africa International Conference 24th – 26th November, Nairobi, Kenya

• Introduction/Background

• Methodology

• Results and discussion

• Conclusion

• Recommendations

• Acknowledgement

Presentation outline

• Samburu County: 21,127 km² • 75% ASAL ecological zone• Population density: 7 people/Sq Km• Poverty index: 59.6%• Illiteracy level: 80%• Active trachoma prevalence: 35% (10% WHO)• Blinding trachoma: 6%(1% WHO)• Safe water access: 31% (59%)• Basic sanitation: 19% (32%)

(World Health Organization)(International Trachoma Initiative)(Ministry Of Health - Kenya)

(UNDP Human Development Report- 2013)

Background

Introduction - Trachoma• Trachoma: Bacterial eye disease; preventable and treatable-NTD• Cause: Chlamydia trachomatis • Transmission: Direct contact (hands and formites) and flies

(Musca sorben)• Primary reservoir: Children aged below 9 yrs• World’s leading cause of preventable blindness• 8M people irreversibly visually impaired Worldwide• 84M cases of active Trachoma Worldwide• 110M live in confirmed endemic & 230M people in suspected areas• Africa is the most affected continent with trachoma >80%• In Kenya, 2nd leading cause of blindness after cataract (19% of the

blind)

• Management approach: SAFE strategy(World Health Organization)

(International Trachoma Initiative)

Conceptual framework

Independent variables Proximal Product

“Evo-Eco” approach (Aunger and Curtis 2013) & social cognitive theory of behavioural change model

•Goal•Self efficacy•Outcome expectation

RESEARCH OBJECTIVES

General: To assess behavioral changes of the pastoral community on fly control and personal hygiene in the management of trachoma

Specific Objectives:• To assess attitude and practices towards eye-seeking

fly control and hygiene in the management of trachoma• To assess knowledge on the link between fly control

and trachoma control management• To identify myths and misconception on latrine usage

and fly control as a vector of trachoma transmission

Methodology• Design: Cross-sectional, descriptive study that

employed exploratory qualitative and quantitative methods

• Study Area: 4 locations in Kirisia Division• Sampling design: - Purposive sampling - Location/Sub-locations- Systematic sampling – HH- Judgmental sampling - KII • Sample size (n): Fisher's = Z2x P x Q d2

=360HH

Methodology cont• Data Collection Tools

– Household interview questionnaire – 361 – Key Informant Interviews- 8– Focus Group Discussion- 6

• Data Entry– Quantitative Data: Ms Access 2007– Qualitative Data: Transcription of recordings verbatin

in MS Word (Samburu to English translation)• Data Analysis

– Quantitative Data: Descriptive statistics (STATA 11)

– Qualitative Data: Thematic analysis using atlas.ti7

Results and DiscussionDemographic

• Of 361 respondents interviewed aged18 - 97 yrs• Majority were female - 69%

Objective 1; Attitude and practices of pastoral communities in management of Trachoma

Facial cleanliness behaviours• 97.8% indicated face washing every day

When I remember 11.6%

Thrice 0.3%

Twice 0.6%

Once 10.8%

Immediately I wake up 88.1%

More than 3 times 1.1%

Thrice 4.0%

Twice 21.8%

Once 61.2%

Non-response 0.3%

Total 100%

Objective1; Leaky tins usage

• 8.86% reported leaky tins utilization on face & hand washing

• Education level did not predict the use of the facility (Kruskal lambda = 0.00)

Face washing, even with a small amount of water, is effective trachoma prevention strategy.(Rabiu et al, 2009)

Dirty face vs clean face (Karimurio et al, 2013)

Leaky tin location

Objective1; Barriers to leaky tins usage

• Main reason reported as barriers to usage were ‘lack of money’ and water scarcity (Goodman and Kruskal tau = 0.013, p = 0.008).

Objective1; Access to latrine

32.78% owned a latrine 67.28% lacked a latrine

Objective1; Barrier to latrine usage

Limited financial resources and low awareness are the major constraint to adoption of sanitation technologies (World Bank programme, 2004)

Objective 2; Knowledge on linkage between eye-seeking fly and trachoma control

• Low knowledge on causative agent (0.6%)

• Majority informed on trachoma transmission (88.1%)

• Aware on risk factors (60%)

• Behaviour change interventions (Gilbert et al, 2013)

Perceived causes of trachoma

Objective 2; Knowledge on linkage between eye-seeking fly and trachoma control management

• 94.4% reported flies were common and mostly attracted to children but 17% does nothing

Effectiveness in reducing fly population reduces transmission (Emerson et al, 2004 & Alhassan et al, 2012)

Fly control methods

Objective 3; Myths and misconception associated with eye-seeking flies

Flies are rampant during wet season - (98.3%) • “Cows eat enough so there is a lot of cow dung”• “Cows breed more producing alot of milk that attracts and

provides enough food to flies hence breed more as well”

Significance of fly among the pastoralists; • “a sign of wealth”• “a sign of abundant food promise” Flies and cattle have been implicated as risk factors for the

trachoma disease (Ngondi et al, 2008) Inverse relationship between socio-economic status and

the risk of trachoma (Murray et al, 1994)

Objective 3: Myths and misconception associated with latrine usage

• Cultural barriers specified; embarrassment, parental and in-law respect

FGD translated quotes;1. “Latrine use is a taboo not fit for morans (youthful men) …

the bush is a blessing from God… so we use it as it is open air and one enjoys the freshness of the air”

2. “Girl child is not allowed to use a latrine her father is using ..”.

3. “It’s a taboo to bury feacal waste of a living human being……”

4. “Its against the culture to dig a hole near the home”.

Conclusion

R1. Perceived “lack of money” and individual knowledge has immense effects on behaviour changes towards trachoma control

R2. Pastoralists are aware of eye seeking fly as a risk factors to trachoma and its control

R3. Key sociocultural misconceptions hindering positive behavioural change among the pastoralist include latrine use taboos and fly significance

Crosscutting: Using the right approach that respect cultural values, pastoralist are likely to embrace desired behavioural changes

RecommendationsCommunity: • Embrace gradual changes through norm modification and

diversified culture interactions• Continued building on positive momentum mindset change to

perception of cost through community awareness campaigns

County Level: • Design and make evidence-based decisions for sustainable

community-led initiatives based on identified barriers • Enhance sustained adoption through community economic

empowerment and knowledge development initiatives• Publically recognize and use community role models as change

agents• To address behavioural change through multi-faceted approach

National level: Formulate policies sensitive and acceptable to the unique pastoralist lifestyle

Acknowledgement

• Samburu County leadership • Community• Junta Castilla y Leon (Donor)• AMREF Kenya ESRC• AMREF Kenya SMT and RABD unit• Research Team