Understanding the Effects of Poor Sanitation on Public Health, the Environment and Well-being Homa Bay County - Report of research findings June 2018 Kenya Country Office Ngong Lane, off Ngong Road P.O. Box 30776, 00100 Nairobi, Kenya Tel.: +254 724 463355 Email: [email protected] Executive Summary Poor sanitation is linked to diarrhoeal diseases, which are among the leading causes of morbidity and mortality in children under five. It is also associated with a number of infectious and nutritional outcomes which have great bearing on the health and well-being of the child. This study was conducted to gain more insights into the effects of poor sanitation on public health, the environment and well-being in Homa Bay County. The results of this case-control study show that the majority of adult respondents (the child’s caregiver) were females (85%), with the majority in both the case and control groups (41%) aged 30-39. A small proportion were aged under 19 (2.5% in the control group and 5.4% in the cases). A considerable proportion of respondents had basic education, with 27.5% of the control group and 31.3% of the case group having completed primary school and 18.9% and 15.8% in the control and cases categories respectively having completed secondary school. About 70% of the respondents lived in their own homes and about a quarter were renting (29% controls and 26.7% cases), with most of the homes being either one- or two- More bedroomed. The results suggest a potential link between household poverty and the respondents in incidence of child diarrhoea: the control group households had higher annual incomes than those in the case group and more control families were in the middle wealth the control had quintile than case families. More households in the case group (73.8%) had borrowed heard sanitation money, food or other items in the past month than in the control group (69%). messages Most of the families (over 60%) had a family member who had ever been diagnosed with some type of chronic illness. The findings suggest that the households have good healthcare seeking behaviour: in about 90% of the households in both categories, sick family members sought treatment and in over two-thirds of the households, they sought treatment in a public health facility. Most paid money for the treatment: more case households (73%) paid for healthcare (in general) than those from the controls (62%). The results show that besides malaria, sanitation-related illnesses are the most common reason the community seeks treatment and that case households bear a bigger burden of sanitation-related illness, compared to the control households. The findings suggest that recurrent diarrhoea in children is likely to be common among the cases: more of the children in the case category had suffered diarrhoea in the two weeks before the survey. Overall, more respondents in the control group had heard messages related to sanitation than did those in the case group, which suggests that exposure to these messages has a link with a child having diarrhoea. The study findings also show a clear link between the household source of water and a child having diarrhoea, but no link between infant feeding practices and the child having diarrhoea. More households in the control group used protected water sources than those in the case group. However, tests on the water collected show that over half of the sampled households in Homa Bay were using water that was contaminated and unfit for human consumption: laboratory tests show that 52% of the water samples collected were contaminated with Escherichia coli (E. coli), a clear indication of contamination with faecal matter. Hand washing was reported to be common, but a physical examination of the homestead by the study team failed to find evidence of using soap in a majority of the homes. The majority of the caregivers said they washed hands after using the toilet, with more caregivers in the control group washing hands (94.8%) than in the case group (86.6%). More caregivers in the control group also reported washing hands before cooking (66%) than in the case group (60%). But the lack of soap suggests that, despite what they reported, most households use water only to wash hands after toilet use, which is inadequate. Understanding the Effects of Poor Sanitation on Public Health and Nutrition - Homa Bay County 1 Most of the households in both groups use unimproved sanitation facilities (traditional pit latrine) and more case households practice open defecation (13.3%) than controls (9%), suggesting a strong link with the child having diarrhoea. Although small in proportion, slightly more households in the case group left a child’s stool in the open (5.4% compared to 3% in the control group) or rinsed it off in a ditch or drain 13.3% of cases (7% compared to 3% in the control group). An analysis of faecal sludge management in the county also reveals that over half of the faecal sludge in the practice open county (52%) is unsafely managed or disposed of, meaning that significant amounts defecation of excreta end up in the environment, polluting water sources. Most respondents (over 60%) in both groups said they use chlorine to treat the water, but about 20% said they do nothing. The study results show that poor sanitation is linked to social discrimination and exclusion of some groups in Homa Bay County, as a result of their inability to have or to use proper sanitation facilities. These groups include the elderly, young children and people living with disability, who may not be able to use the conventional pit latrines. Some of the findings also suggest that there may be security concerns that prevent some groups from using household toilets at night and that some cultural norms also impact on access to sanitation for some groups. To address the challenges established through this study, it is recommended that the county government and partners take action to, among other things, improve sanitation coverage and promote public education on sanitation and hygiene. The county should put more efforts into securing the quality of drinking water by increasing improved water supply. This can be achieved by developing new water points and upgrading existing unimproved sources. Improving access to clean water supply not only increases the quantity of clean water available for household consumption but also allows households to save much time by reducing the distance between each household and the nearest water access point. A collapsed latrine in Wang’chieng Understanding the Effects of Poor Sanitation on Public Health and Nutrition - Homa Bay County 2 Table of Contents Executive Summary ................................................................................................................... 1 Table of Contents ...................................................................................................................... 3 List of Tables and Figures ......................................................................................................... 4 List of Abbreviations ................................................................................................................. 5 Chapter 1: Introduction ............................................................................................................. 6 Chapter 2: Study Design and Justification ..............................................................................10 2.1 Methodology Overview ............................................................................................... 11 2.2 Sampling .................................................................................................................. 12 2.3 Data collection techniques ........................................................................................... 12 Chapter 3: Key Findings ..........................................................................................................16 3.1 Socio-economic status of selected families and household characteristics ........................... 17 3.2 Effects of poor sanitation on public health, the environment and well-being for the different groups in the county population......................................................................................... 20 3.3 Social effects of poor sanitation on different groups (age, gender, ability) in the country population ........................................................................................................... 31 3.4 Political role and economic cost of poor sanitation in the selected counties ......................... 33 3.5 Effects of poor sanitation on the environment ................................................................ 34 3.6 Implementation of sanitation activities by Homa Bay County ............................................ 35 Chapter 4: Conclusions and Recommendations .................................................................... 38 Annex: Water testing protocol used in this study .................................................................. 42 Understanding the Effects of Poor Sanitation on Public Health and Nutrition - Homa Bay County 3 List of Tables and Figures Table 1: Summary of data collection methods used in the study ............................................. 14 Table 2: Proportion of children who had diarrhoea in the two weeks prior to the study and the treatment received .......................................................................................................... 21 Table 3: Breastfeeding