MATERNAL BELIEFS AND BEHAVIORS IN THE PREVENTION OF
CHILDHOOD DIARRHEA IN DAR ES SALAAM, TANZANIA
PROGRAM IN HUMAN BIOLOGY HONORS THESIS STANFORD UNIVERSITY
JESSIE LIU Class of 2009
I certify that I have read this thesis and that in my opinion it is fully adequate, in scope and quality, as an undergraduate thesis for the degree of Bachelors of Arts with Honors.
__________________________________ _____________ Dr. Paul Wise, Principal Reader Date
__________________________________ _____________ Dr. Jennifer Davis, Secondary Reader Date
ii | P a g e
ABSTRACT Childhood diarrhea causes nearly one-quarter of under-five deaths in Tanzania, and it is the third-leading pediatric diagnosis in Dar es Salaam hospitals. Simple treatments such as oral rehydration salts have decreased mortality caused by diarrheal illness but not morbidity. Preventive health behaviors performed by caregivers are crucial to decreasing the poor health outcomes caused by chronic diarrhea. In this quantitative study, 311 caregivers in Dar es Salaam were interviewed to explore the relative influence of sociodemographic factors, beliefs, and knowledge on behaviors reported by caregivers or observed by survey enumerators. The behavioral outcomes in question were hand hygiene, sanitation, proper treatment of water for drinking or cooking, and use of ORS when an under-five child had diarrhea. Data was analyzed by descriptive, univariate, and multivariate methods using SPSS. Findings suggest that the relationships between maternal beliefs and preventive behaviors are more complex than previously shown, because the relationships between beliefs and behaviors are often mediated by sociodemographic factors. However, perception of self-efficacy was substantively associated with performance of all behaviors, and empowerment was significantly correlated with reported water treatment, all else held constant. Knowledge of risk factors for childhood diarrhea was found to be insignificant with relation to all behaviors. Results from this study show that a multilateral approach by policymakers, public health educators, and community leaders is necessary to promote preventive behaviors performed by caregivers to prevent childhood diarrhea in Dar es Salaam.
iii | P a g e
ACKNOWLEDGMENTS To my faithful supporters,
Dr. Paul Wise, thank you for the generous amount of time you spent with me hashing out everything from the small details to the big-picture ideas. Each time I spoke with you about my concerns with my data analysis / conceptual framework / life in general, you provided just that boost or perspective I needed. Thank you for your unwavering faith and for the past three years of life-coaching.
Dr. Jenna Davis, this project would not have been possible without you, Ali, Amy, Kirsten, Annalise, and all of our partners. Thank you for providing me with the opportunity to work in Dar es Salaam this past summer. I have continuously been inspired by your compassion and high standards of scholarshipfrom the summer before when I was doing the daycare hand hygiene project to our long days at Colubus Hotel. Ive asked you many a time for a lifeline of statistical wisdom or research focus, and you never let me down.
Tanzanian partners: the survey enumerators, Eddy, Douglas, Freddie, Health and Environment Rescue Organization, Muhimbili University of Health and Allied Sciences, District Hospitals of Mwananyamala, Ilala, and Temeke, thank you for all of your hard work this past summer. I greatly appreciated our discussions regarding every aspect of childhood diarrhea, Tanzanian culture, and the healthcare system in Dar. I had the pleasure of getting to know many of you better during the time I was in Dar, so thank you for your friendliness and enthusiasm.
Dr. Virginia Visconti, those of us who have had the honor of working with you this year have benefited from you as a proactive source of wisdom and encouragement. Thank you for your dedication to helping each of us in PSSP get the most out of the experience, for your meticulous edits, and investment in each of our thesis.
PSSP-ersAndrea, Anjali, Kelley, Meredith, Scott, Stany, Theresa, Tomiwe made it! I still remember that first notecard we filled out and shared with each other, and tens of notecards later, each of us have a thesis we should all be extraordinarily proud of. I cant thank you enough for our weekly support group sessions. Seeing all the work and enthusiasm you each dedicated to your own theses motivated me to pick up the slack when I let work on my thesis slip. You are some of the most inspiring individuals Ive met at Stanford, in and out of academia. I crown you all masters of Vikingdom, and I cant wait to hear about what all the amazing things each of you will be doing in the years to come!
Theresa, on that fateful day when we stood next to each other in line on move-in day freshman year, I couldnt have imagined in my wildest dreams the epic adventure we were about to embark
iv | P a g e
on to bring us to where we are today. I know youre not super techy, but I feel like weve proved Einsteins time paradox; four years has somehow gone by, and I feel like weve known each other for several times that. Rooming with you this past year has been the highlight of senior year. Thanks for the peals of laughter, the votes of confidence, and the tidbits of wisdom. As we go forth and brave the real world, dont lose that spark of spontaneity.
Jia, thank you for all of your help when I was swimming in circles in my pool of data. I truly appreciate the time you took out of your days to sit with me to hone my data analysis plan. Thanks for jumping right in to help me and for serving as a great data analysis advisor.
Alex MacMillan, thank you for meeting with me on multiple occasions and the critical perspectives you provided when I was in the midst of analyzing every corner of the raw data.
Amy, Kiki, Annalise, Ali, and Helena, when we were in Dar, I appreciate your putting up with me when I had to take a step back from the main project to work on my thesis. While the hospital data made a minimal contribution to my thesis, and I was forced to discard the interviews, the exploration was critical to increasing my understanding of the issues discussed here. Thank you for being flexible, understanding, and encouraging.
All my friends, each of you has been as critical to the completion of this thesis as each hour Ive slaved away at it. Im grateful to all of you for pulling me out in the middle of the night to go adventuring, all the you gotta go because its senior year cajoling, and for caring for my well-being during the rougher times. You have made my time at Stanford infinitely more rewarding. As we find ourselves flung out to all corners of the world, youll continue to be my rays of happiness and inspiration.
Mom and Dad, thank you for instilling in me the belief that I can accomplish anything I put my mind to and for having confidence in my ability to do so. Im indebted to you for all the freedom of choice, thought, and action youve given to your all-too-adventurous daughter.
Funding for this study was made possible by a Major Grant disbursed by the Vice Provost for Undergraduate Education
v | P a g e
TABLE OF CONTENTS I. Preface ................................................................................................................................................................ 2 II. Research questions .......................................................................................................................................... 6 III. Literature review ............................................................................................................................................ 7 A. Under-five health .................................................................................................................................... 7 1. Global child survival ......................................................................................................................... 7 2. Child survival in sub-Saharan Africa .............................................................................................. 9 3. Child survival in Tanzanial............................................................................................................. 10 B. Maternal characteristics and child health ........................................................................................... 10 1. Education ......................................................................................................................................... 10 2. Socioeconomic characteristics ....................................................................................................... 11 3. Self-efficacy and health behavior theories ................................................................................... 12 4. Empowerment ................................................................................................................................. 13 C. Dar es Salaam ......................................................................................................................................... 14 1. Geographic location and demographic information ................................................................. 14 2. Sanitation services and infrastructure .......................................................................................... 15 3. Provision of clean water ................................................................................................................. 17 4. Healthcare reform and its current state ....................................................................................... 17 5. Under-five diarrheal illness ............................................................................................................ 19 6. District hospital records of diarrheal illness ................................................................................ 21 D. Why preventive child health, maternal beliefs, and Dar es Salaam? ............................................. 23 E. Methodology review ............................................................................................................................. 26 IV. Methodology ................................................................................................................................................ 28 A. Geographic location.............................................................................................................................. 28 B. Community partners ............................................................................................................................. 29 C. Survey tool .............................................................................................................................................. 30 1. Survey enumerator training............................................................................................................ 31 2. Household surveys .......................................................................................................................... 33 3. Quality control ................................................................................................................................. 34 4. Language and translation ............................................................................................................... 34 D. Data analysis .......................................................................................................................................... 34 1. Definition of variables .................................................................................................................... 34 2. Statistical analysis ............................................................................................................................. 36 3. Reporting of results ......................................................................................................................... 38 V. Results ............................................................................................................................................................. 39 A. Descriptive results ................................................................................................................................. 39 1. Household characteristics .............................................................................................................. 39 2. Water and sanitation services ........................................................................................................ 41 3. Health of household and health practices ................................................................................... 44 4. Characteristics of maternal head of household .......................................................................... 45 5. Maternal knowledge, beliefs, and perceptions ............................................................................ 45 B. Univariate results ................................................................................................................................... 47 1. Beliefs and knowledge vs. behaviors ............................................................................................ 49 2. Sociodemographic characteristics vs. behaviors ......................................................................... 50
vi | P a g e
C. Multivariate results ................................................................................................................................ 54 1. Multivariate binary logit analyses of reported and observed behaviors.................................. 54 2. Multivariate binary logit analyses of beliefs, perceptions, and knowledge ............................. 57 VI. Discussion ..................................................................................................................................................... 61 A. Key findings ........................................................................................................................................... 62 1. Evaluating the role of self-efficacy ............................................................................................... 62 2. Evaluating the role of empowerment .......................................................................................... 65 3. Evaluating the role of motivation ................................................................................................. 67 4. Evaluating the role of education vs. knowledge of risk factors ............................................... 68 5. Evaluating the role of religion ....................................................................................................... 70 6. Evaluating the role of number of families in responden'ts house ........................................... 72 B. Limitations .............................................................................................................................................. 73 C. Recommendations ................................................................................................................................. 76 VI.I Conclusion .................................................................................................................................................. 78 APPENDIX A: Detailed discussion of choice of variables ........................................................................ 80 APPENDIX B: Survey questionnaire ............................................................................................................. 85 References ............................................................................................................................................................ 90
vii | P a g e
LIST OF TABLES Number Page Table 1: Under-five patients at national district hospitals in Dar es Salaam: Diagnoses and deaths related to diarrheal illness (Jan. 2005-June 2008) .................................. 22 Table 2: Sociodemographic characteristics of households and respondents ............................ 40 Table 3: Descriptive results of knowledge, attitudes, and perceptions of respondents ........... 46 Table 4: Chi-square univariate analyses of preventive behaviors relating to childhood diarrhea by belief/perception ..................................................................................... 52 Table 5: Chi-square univariate analyses of behaviors vs. sociodemographic characteristics and beliefs. ........................................................................................... 53 Table 6a: Determinants of reported preventive behaviors for childhood diarrhea ................. 58 Table 6b: Determinants of reported preventive behaviors for childhood diarrhea, reduced models .............................................................................................................. 59 Table 7: Determinants of maternal beliefs and perceptions ........................................................ 60 Table 8: Distribution of sociodemographic characteristics, beliefs, knowledge, and behaviors ......................................................................................................................... 83
viii | P a g e
LIST OF FIGURES Number Page Figure 1: Summary of studies that have analyzed the effect of maternal educaiton after controlling economic factors ....................................................................................... 11 Figure 2: Theoretical model of relationships between factors influencing child health outcomes with relation to diarrheal illness................................................................. 47
2 | P a g e
3 | P a g e
I. PREFACE I looked at the bony bundle, minus one large protrusion of a belly, lying limp in his mothers arms. I feared that if he breathed too heavily he may shatter the ribs glued onto the skin of his chest, or if he blinked he might tear the skin pulled so tightly around his scalp. His arms waved frailly through the air, as though grasping for words he was too young to know to protest his sickly state caused by malnutrition. The other children in cribs had been in Clemencias malnutrition ward for a long time recuperating, but this one was a newcomer, fresh out of the cloud forests from the highlands of southwestern Guatemala. All the children brought with them similar symptoms similar, but the differential diagnoses for why they came to the ward varied. Sometimes young mothers were unable to breastfeed or did not breastfeed until an appropriate age. Other times, children transitioned to solid food prematurely, or the solid foods were virus-, bacteria-, or parasite- ridden. Not to be forgotten were the cohorts of waterborne, water-based, water-related, or water-washed illnesses, nearly all targeting the fragile ecosystem within a young childs gastrointestinal tract. Entamoeba histolytica, rotavirus type A, serotypes G1-G4, Ascaris lumbricoidesall of these and thousands more infective agents attacked tip cells that absorb water in the small intestine or diverted nutrients meant for the pediatric host. In areas laden with poverty and poor sanitation, the cycle of diarrhea is difficult to break. At the time, I was working as a public health volunteer for a month in Pueblo Nuevo, Guatemala. Each day, we handed out jarabes and tabletas of metronidazole or albendazole to mothers to excise the amoebas or worms that plagued their children. Each medication was
4 | P a g e
accompanied by advice about boiling water adequately, providing children with a diet beyond over-salted beans and tortillas, making sure children and adults defecate in latrines, ensuring good handwashing practices after defecation and before eating, preventing flies from hovering around food and excrement, and keeping animals within fences and disposing of their feces promptly and properly. Most of these recommendations were politely heard and then pushed aside by more pressing matters, such as food, work, and money. For six weeks prior to going to Guatemala, I researched child hand cleanliness and parents knowledge, attitudes, and perceptions of diarrheal illness in another world: upper- middle class, California Bay Area daycare center. Nearly all children had had a diarrheal incident in the last year, but parents rarely considered the case serious. If they sought treatment, they had ready access to Pedialyte or a had a doctor who would recommend Pedialyte and provide reassurance of recovery. Many of them were concerned about the viruses their children were exposed to at daycare centers and later brought home to show-and-spread to other siblings. But these kids were lined up single-file before every snack and lunch and paraded through a bathroom where one of three attentive teachers would help them scrub their hands clean with soap and water before marching them back out for that days healthy snack, carefully rationed and balanced with the other foods that would be served that day. To my Guatemalan homestay mothers and the nine kids between them, this ceremony would have been ludicrous. Bananas and greens picked from the hillside were the only non-carbohydrates they could afford or have access to, and children washed their hands with laundry detergent when they could sneak it from their mothers stashes. The young child I saw in Clementias malnutrition ward was just one of an estimated 200,000,000 people with gastroenteritis during any given 24-hour period. The volume of his diarrhea would contribute to the total amount of diarrheal water passed in 24 hours, which has been estimated to equal the amount of water passed over Victoria Falls each minute (Greenberg 2005). If the young child were to stop breathing, he would be one of 1400 children believed to die of diarrhea each day (PATH 2009). Diarrheal illness is one of the neglected diseases of the world. Illnesses like HIV/AIDs, tuberculosis, and malaria receive much more attention and funding than the two biggest causes of under-five mortality: pneumonia and diarrhea. Unlike these Big Three, the etiology of each case of diarrhea is usually unknown. It cannot be traced back to mother-to-child transmission, one partner with whom the patient had unprotected sex, exposure to someone coughing up blood, or inoculation of the parasite by an Anopheles
5 | P a g e
mosquito. There is no clear course of transmission that a public health official can identify and lobby to intervene upon. Instead, multiple pathways that involve complex infrastructure and social systems are culprit, and they funnel down to individual perception and social norms. In January of 2007, Professors Alexandria Boehm and Jennifer Davis offered to take me on as a research assistant for a project investigating water, child health, and sanitation in Dar es Salaam, Tanzania (Dar). The project was borne out of collaboration between social science inquiry through household surveys and microbiology testing for fecal indicator bacteria. This was the perfect intersection between my interest in the hard sciences and social sciences. When conducting research in the Peruvian Amazon and in the California Bay Area daycare study, I used a mixed-methods approach to generate qualitative and quantitative data. While this project in Dar es Salaam would not include interviewing, I thought that it was a unique opportunity to compile a rich dataset of survey results and corresponding microbiology data. Given my experiences in Guatemala, I would have loved to return there to conduct research for my thesis with the village I worked in the summer before, but I decided that the benefits of learning from individuals with much more research experience than myself and the likelihood of data collected by the team being much more robust than what I could accomplish alone were worth the tradeoff. I arrived in Dar three days after I had taken my last final exam. Upon arrival, a Tanzanian driver we had hired for the project, Eddy, met my travel buddies and I to chauffeur us to our new home for the next few months. Trainings were beginning in just a few days, so we went straight to work preparing materials. The next three weeks were a blur of training sessions, conversations with enumerators, and pages upon pages of translated surveys with marked-up corrections. During that time we set up our microbiology lab in the Richmond apartment complex. My dominant memory of that time was this excited flurry of anticipation. I also used this time to orient myself and explore Dar culture, specifically with regard to health. In my freshman year, I took a medical anthropology course at Stanford, and since then, I have been fascinated by the social and cultural factors that influence individual perceptions of health, illness, and risk factors. Dar was a new classroom, and I took every opportunity to avidly learn from my peers. Tea and lunch breaks during training sessions provided a unique opportunity to play anthropologist and to ask our survey enumerators questions about perceptions of health and death (and therefore life since the two are inextricably linked).
6 | P a g e
Two things stuck out for me from those conversations were: 1) the high frequency of illness and death and 2) the disempowerment of women and their perceived lower social status relative to men. I made both of those observations in the developing countries I had visited previously, but not to this extent. I had also spent less time in those other places. In Dar, I was fascinated by how those two phenomena ingrained themselves in everyday conversations. Every Tanzanian I talked to had had a close family member or friend pass away prematurely. Malaria was so commonplace, it was thrown around as an excuse for missing work or being late, the same way the excuse the dog ate my homework is used by students in the United States. Tanzanians I talked to were surprised that both sets of my grandparents were still alive, and I was taken aback by the casualness used in describing an injury caused by a hit-and-run while biking to work, or how text messaging was an acceptable form of notification for a close family death. People rationalized premature death in many ways. Among our college- or secondary school-educated enumerators, they saw it as the way it was because of poor sanitation, hygiene and inadequate healthcare provision. Even those who received formal education or were religious (Muslim or Christian) believed in spirits. One individual attributed his fear of the ocean and why he did not swim to the malicious spirits who live in the oceanthe souls of individuals who have passed away seek to make mischief on those still in the world of the living. He cited the time, years ago, when he had lost a friend to the ocean spirits, the most-recent in a line of people he knew who had been lost to the sea. This sense of fatalism and a world manipulated not by those in and of it led me to explore its academic interpretation in my own research. Especially in a male-dominated society like Dar, I was interested in what level of control mothers perceived they had in their childrens health. Did they think diarrhea was something that could be prevented? Did they know how to prevent it? If they did know, what factors influenced whether or not they performed certain preventive health behaviors? I decided I wanted to look at several of the key beliefs and perceptions, such as self-efficacy, empowerment, and motivation, which I believed would be necessary for health behavior change or reinforcing positive habits. The document that follows is the culmination of my interest in infectious disease, social factors influencing health outcomes, global health, and self-motivated health habits. I am greatly indebted to all of the individuals who have contributed to this research and who have accompanied me through the all the mountains of joy and frustration during this process.
7 | P a g e
II. RESEARCH QUESTIONS What factors influence the behaviors mothers practice that can help prevent their children from getting diarrheal illness, and what are the relationships between these factors?
1. What influence do beliefs and perceptions (self-efficacy, empowerment, and motivation), knowledge of risk factors for diarrheal illness, and sociodemographic characteristics have on the following preventive health behaviors: a. Hygiene (handwashing habits) b. Sanitation (presence of feces around latrine) c. Water treatment (proper treatment of water used for drinking/cooking) d. Home treatment (preparation of oral rehydration salts when under-five child has diarrheal illness) 2. What is the relative importance of health knowledge in comparison to these beliefs/perceptions? 3. Is health knowledge or any one of the beliefs/perceptions a sufficient factor for predicting health behaviors? 4. How can public health campaigns be more effective in ensuring positive health behavior changes in mothers to prevent under-five diarrheal illness?
8 | P a g e
III. LITERATURE REVIEW A. Under-five health 1. Global child survival Rates of under-five mortality and morbidity have been greatly reduced in developed nations, 1 but as many as 98% of under-five deaths occur in developing nations. Around the world, child mortality rates vary from 3 to over 280 deaths per 1000 live births (WHO Statistics Division 2005). Throughout history, parents acceptance of the possibility of their children dying before reaching the end of their first month, their first year, or first five years has contributed to keeping fertility rates high. However, affordable interventions have been successful in reducing the global under-five mortality rates in areas where these interventions have become available. Interventions such as antibiotics, oral rehydration salts and zinc supplements, and insecticide- treated bednets and anti-malarials are effective against the three biggest child killers after a child survives the neonatal period: pneumonia, diarrheal illness, and malaria. According to the Demographic Household Surveys and Multiple Indicator Cluster Surveys, global under-five
1 Defined by the International Monetary Fund as nations possessing a Human Development Index score of 0.9 or higher.
9 | P a g e
deaths fell below 10 million, to 9.7 million in 2006 for the first time in modern history (UNICEF 2008). Despite all of these improvements, the world is not on track to meet the child survival Millennium Development Goal (MDG) of a two-thirds reduction in child mortality between 1990 and 2015 (UNICEF 2008). Given current rates of population growth and child mortality, if the child survival MDG were achieved, about 5.4 million child deaths would be averted each year. Significant challenges to achieving the child survival MDG exist. Some of these include barriers to distributing basic supplies, quality of healthcare, and access to healthcare services. In many regions, women and children bear the brunt of health disparities. For example, in patriarchal families, males occupy a position of power, and the needs of women and children are subordinate to those of the male head. Studies have shown in households where the male controls family spending, the percentage of the household income spent on education, health, and childrens necessities is less than households where women have some decision-making power (Heggenhougen et al. 2003; WHO 2008). In populations that do not have adequate resources to meet their nutritional health needs, stunting and undernutrition are common among under-five children. Stunting is defined as being two standard deviations shorter than the median height of children at a certain age, compared to an international reference population. Undernutrition is a broader description of a collection of outcomes that results from insufficient nutritional intake and repeated illness. Undernutrition has been cited as the cause of over 50% of under-five deaths (UNICEF 2008), and survivors suffer developmental impairments at physical and intellectual levels. Undernourished children are more susceptible to disease, and without adequate energy reserves to stimulate an immune response, they face greater challenges in recovery. Children who are already malnourished and suffer an acute diarrheal episode will have more difficulty recovering;
10 | P a g e
the nature of the illness leaches away already-limited nutrients and fluids the body needs to sustain itself. Even if the child recovers, the conditions of poverty that led to the first diarrheal episode are likely to persist, which can lead to more serious health outcomes.
2. Child survival in sub-Saharan Africa Undernutrition is especially rampant in sub-Saharan Africa (SSA). An estimated 225 million people, or 28% of the population, living in SSA are undernourished. SSA also has the highest rate of childhood stunting at an estimated 43% (Teller and Alva 2008). Mortality rates and disease burden are also high throughout the region. Although only 12.1% of the worlds population is found in SSA (World Bank 2008), of the 9.7 million estimated child deaths in 2006, 49.5% were children living in SSA (UNICEF 2008). If current trends persist, by 2015, SSA could account for up to 60% of child deaths (Bennett 2007). Because of the increasing disparity in under-five mortality between regions around the world, child survival should be seen as a priority in SSA development and as part of the struggle for human rights (UNICEF 2008). Global partnerships are working to provide comprehensive care for mothers and their children, and to obtain resources necessary to make these plans possible. The joint international agency for maternal and child survival in Africa estimates that it would cost about US $2.50 per capita per year to scale up existing interventions that can reduce child mortality by 35% by 2009 (UNICEF 2008). Many major industrialized nations have pledged to double their aid to Africa by 2010 at a meeting in Gleneagles, Scotland in 2005. In addition, African nations who signed the Abuja Declaration in 2001 pledged to allocate 15% of their national budgets toward health. Making good on those pledges will be important in amassing a critical amount of funding that will make a lasting difference in reducing child mortality.
11 | P a g e
3. Child survival in Tanzania Tanzania, located on the coast of the Indian Ocean in East Africa, is on the list of 60 priority countries for the child survival MDG. Countries with an under-five mortality rate (U5MR) of over 90 per 1000 live births and with more than 50,000 child deaths per year are on this list. Tanzanias U5MR has been decreasing in the last couple of decades, from 161 per 1000 live births in 1990 to 118 in 2006, but it is still the 34 th highest rate in the world (WHO World Health Statistics 2008). In 2000, when U5MR was 141 per 1000 live births, the distribution of the cause of death for under-five children was as follows: neonatal (26.9%), malaria (22.7%), pneumonia (21.1%), diarrhea (16.8%), HIV/AIDS (9.3%), injuries (2%), and measles (1.3%). Due to the high U5MR, high maternal mortality rate (950 per 100,000 live births), high prevalence of communicable diseases, and high injury rates in urban areas, the life expectancy at birth is 50 for males and 51 for females (WHO World Health Statistics 2008). High child mortality rates contribute to the decision to have large families, and in Tanzania fertility rates have held stable for the last 10 years at 5.7 nationwide, and 3.6 children per woman in urban areas (NBS 2005).
B. Maternal characteristics and child health 1. Education The positive correlation between maternal education 2 and child health outcomes is well- established. One study in Bangladesh conducted by White (2005) showed that a child whose mother completed primary school is 20% more likely to survive than a child whose mother has
2 Maternal education refers to formal, institutional schooling, though the author recognizes that education can and does frequently occur in informal settings.
12 | P a g e
Figure 1. Source: Cleland and Van Ginneken 1988. not received any formal schooling, and a child born to a mother who attended secondary school is 80% more likely to survive. Cleland and Van Ginneken (1988) found that each additional year of education a mother receives corresponds to a 7-9% decline in under-five mortality. Multiple conduits have been proposed to explain how increased education influences child mortality. More years in school for a woman can translate into better outcomes, such as: marriage later in life, later first childbirth (the risk of maternal mortality is 2-5 times greater for a woman under the age of 18 than over the age of 20 (Murray 2007)), a higher chance of better nourishment, and more decision-making power in the household on health-related or child-related matters.
2. Socioeconomic Characteristics Socioeconomic status (SES) is one confounding factor for why the relationship between maternal education and childrens health outcomes is significant. However, the UN concluded that only half of the improvements seen in households with an educated mother can be attributed to economic advantage. When SES is controlled for, maternal education still has
13 | P a g e
significant effects (Cleland and Van Gitteken 1988). Figure 1 is a summary of multiple studies that have assessed the influence of maternal education, all other factors held constant.
3. Self-efficacy and health behavior theories Many health knowledge campaigns operate based on the assumption that knowledge is both necessary and sufficient for health behavior change. However, health behavior theories incorporate attitudinal and social factors that motivate and reinforce changes. Some prominent health behavior theories include the health belief model, the stages of change model, the cognitive information-processing model, the theory of reasoned action, and social cognitive theory (Elder et al. 1999). The health belief model catalogs the variables of perceived susceptibility, seriousness, benefits, and barriers as variables in a function much like a multivariable logistic regression, with behavior as the dependent variable. The stages of change model names six stages critical to the process of behavior change: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, 5) maintenance, and 6) termination. Of the models mentioned above, the cognitive information-processing model puts greatest weight on informational processing and procedural or sensory knowledge. The theory of reasoned action underscores outcome expectancy, attitudes, and normative beliefs regarding the behaviors that are influenced by social factors. Social cognitive theory also incorporates outcome expectancy, but emphasizes self- efficacy, or a perception of oneself being capable of performing certain skills to attain some outcome. The theory behind this model builds from the research of Bandura (1977). Bandura hypothesized that self-efficacy is a function of performance accomplishments, vicarious experience, verbal persuasion, and diminished fear. Through multiple experiments, he showed that perceived self-efficacy was a better predictor for a certain behavior in the face of the
14 | P a g e
unknown than past performance could predict. Self-efficacy has been identified as an influential factor in the practice of many preventive health behaviors, such as administration of self-breast examinations (Jirojwong and MacLennan 2003) and the behaviors caregivers use to prevent their children from getting lead poisoning (Kegler et al. 1999).
4. Empowerment Increased maternal economic and social autonomy have also been robustly correlated to better child outcomes (Koenen et al. 2006). Intra-household relations have been found to affect decision-making dynamics regarding when and what kind of treatment to seek for a child with malaria (Molyneux et al. 2002). African households are mostly patriarchal, and the male head asserts authority over his wife and children. The wife is responsible for childcare and maintenance of the home and family, and for this reason, mothers have traditionally been targeted subjects of health knowledge campaigns. However, their husbands can withhold economic resources necessary for care and preventive measures. As one Kenyan woman expressed in an interview with Molyneux (2002, 118): If a child is well, Ill make sure Im taking care of him by feeding him, washing his clothes, and observing him for any signs of illness. In case I find hes unwell Ill have to inform the father who decides on the treatment . . . Hes the one to decide on whether the child should be taken to the hospital or where. . . If its by giving money to the hospital or advice on what to do.
Another study found similar results. Although women may be the first to recognize danger signs, they are not necessarily enabled to take appropriate action (Heggenhougen et al. 2003; Montgomery et al. 2006; Sethuraman et al. 2006). Montgomery et al. (2006) found that, contrary to what health personnel thought, women in the Tanga district of Tanzania had strong knowledge of the etiology, symptoms and treatment for malaria. Since health personnel constantly saw these women bringing their children to medical facilities late, they concluded
15 | P a g e
that the women were lazy and uneducated. Education campaigns targeted at women may actually be disempowering, if, as this study suggests, women have sufficient knowledge, but do not have decision-making power to exercise what they know. Sethuraman et al. (2006) examined the role of womens empowerment in the nutritional status of children and maternal nutrition in rural and urban India. Through multivariable linear regression, the researchers found that health-care seeking and womens empowerment variables were significantly associated with child nutrition, with womens empowerment variables explaining 5.6% of the variance. Socioeconomic variables had the most tenuous connection to child and maternal malnutrition. Mental and psychological abuse and sexual abuse increased the risk of malnutrition in both children and mothers; 34% of women in the sample had experienced domestic violence.
C. Dar es Salaam 1. Geographic location and demographic information Dar es Salaam (Dar), Arabic for city of peace, is the largest urban center in Tanzania. Its prime location on the Indian Ocean for good harbors caught the attention of Arabs 148 years ago when it was established as a trade center (Chaggu et al. 2002). Dar was the capital of Tanzania until 1996 when the National Assembly moved to Dodoma, but Dar has remained the commercial center for the nation. The population of the city is expanding rapidly. With an annual growth rate of 4.39%, Dar has the 3 rd -fastest growth rate in Africa, and 9th-fastest in the world (City Mayors 2006). In the 1950s, Dar had 150,000 inhabitants, and in 2007, the World Bank reported that Dar was home to 2.8 million residents.
16 | P a g e
The city was estimated to cover 197.3 km 2 in 1996, but because Dar is largely unplanned and the vast majority of the city is composed of densely populated, unstructured squatter settlements, it is difficult to set explicit boundaries on the city (Chaggu et al. 2002). Dar is organized into three districts, Kinondoni, Ilala, and Temeke, from north to south. Each of these districts is subdivided into divisions, then into wards, then into streets, and then into tencells. Leadership exists at each level to govern within its respective boundaries. Squatter settlements are prevalent outside of the downtown area, and despite Dar being the hub of Tanzanias commerce, money and profits are not trickling down. Health, water, and sanitation infrastructure have struggled to keep up with the influx of people.
2. Sanitation services and infrastructure Worldwide, it has been hypothesized that improved sanitation alone could reduce morbidity caused by diarrheal illness by more than one-third; combined with better personal hygiene, it could reduce morbidity by two-thirds (UNICEF 2008). Similarly, better handwashing techniques, complete with soap or ashes, can decrease diarrheal illness by as much as 35%. Sanitation services in Dar do not meet the needs of its inhabitants. Citywide law mandates that every housing structure built on a plot of land must have a pit latrine, and it is estimated that 95% of household plots (which may house multiple families) has a pit latrine. However, only a small percentage of the Dar population is connected to the sewage system or practices safe excreta disposal (Lugalla 1995). The Dar central sewerage and drainage system was constructed under colonial times, and the infrastructure is only able to address 10% of the need. Owners of pit latrines and septic tanks are responsible for emptying human waste, either by hiring someone else to do it or doing it themselves. The cost of hiring someone to do it is often a deterrent, especially if the waste is disposed of following properly. However, the pit
17 | P a g e
latrine may be emptied illegally if workers dig a hole in close proximity of the latrine and then drain the waste into a mini-landfill. This informal method of waste exposal increases the risk of groundwater contamination and biohazardous material in such close proximity to the house. The Ardhi Institute (1993), which conducted its research in one of the three wards in this study, found that about 60% of health complaints in unplanned areas of Tanzania can be traced to groundwater contamination from pit latrines. Based on 207 household interviews, Chaggu et al. (2002) concluded that most households did not put priority on safe excreta exposal. In these households where about 75% of household spending was for food, little money was left over to spend on education, health, and sanitation. At the household level, the study found that 34% of small children defecated in the house, and 37% use the courtyard. Parents then scooped up the feces and dumped them in the pit latrine or onto the waste heap. Only 5% of children defecated in special pots so that mothers were able to avoid as much close contact with feces as possible. To clean themselves, 1% of the sample population reported use of toilet paper; the remaining 99% used water for anal cleaning or a mix of toilet paper and water. Combined with a poor wastewater and waste management system, water-related illnesses were found to be highly prevalent. The study concluded that decreasing the burden of diarrheal disease would require household members to consistently use latrines for defecation, young childrens feces to be disposed of properly in the latrine, and all individuals to wash hands with soap or ash after defecation and before eating (Chaggu et al. 2002). Because most diarrheal episodes are caused by pathogens that are spread through fecal-oral pathways, simple public health interventions such as safe disposal of human waste and proper handwashing can be highly effective to prevent transmission.
18 | P a g e
3. Provision of clean water Adequate provision of clean water can help prevent childhood diarrhea. In Dar, individuals obtain water from public or privately-owned taps that draw water from boreholes, tanker trucks and water vendors who provide a mobile water source, shallow wells, surface water sources such as rivers and ponds (NBS 2005). Cholera outbreaks during the rainy season and other water-borne diseases throughout the year continue to plague the city. In an attempt to ameliorate this, in 2003, the Tanzanian government received US$164.5 million in credit from the World Bank (International Development Association) to fund the Dar es Salaam Water Supply and Sanitation Project. The purposes of the project included capacity building and the rehabilitation and extension of the distribution pipe network (World Bank 2003). Through the work done by the Dar es Salaam Water and Sanitation Authority, the project has increased the number of public taps and borewells. The water distribution network targeted for repaired was over forty years old and had allowed the recontamination of treated water (Dar es Salaam Public Health Delivery System 2000, qtd. in Mayo 2007). However, nearly half of the taps in one ward, Sitakishari/Majumbasita, were estimated to have fallen into disrepair due to inadequate maintenance (personal communication, Sitakishari Water Committee Chair).
4. Healthcare reform and its current state The present system of healthcare in Dar came into existence after an economic downturn in the 1980s and 1990s debilitated health infrastructure. The poor quality of care prompted the Dar es Salaam Urban Health Project (DUHP). The goal was to improve the health status of the population through improved healthcare delivery by bolstering the existing system with improved structure, function, and a sustainable financial basis (Harpham and Few 2002). The project ran from 1990-2000 and received approximately US$21 million from the Swiss
19 | P a g e
Agency for Development and Cooperation. Rather than approaching it from top-down mandates, the DUHP focused on bottom-up planning through annual action plans by community-level health dispensary units. Dispensaries would identify problems they saw with service delivery, varying from inadequate infrastructure to inadequate trained personnel, and under the guidance of health boards with community representation, would form facility plans that were then merged into municipal plans. The bottom-up planning strategy reflected Dars referral system. Dispensaries (i.e., public or private community clinics) are at the ground level, and they are equipped to perform basic procedures, such as treating common illnesses and providing skilled attendance at birth. Dispensaries refer patients to larger health centers or to district hospitals. There are three district hospitals, one for each municipality: Mwananyamala District Hospital in Kinondoni, Amana District Hospital in Ilala, and Temeke District Hospital in Temeke. If these hospitals see cases they are unable to treat, patients are sent to Muhimbili National Hospital (Tanzania Ministry of Health 2003). The DUHP neglected to adequately address environmental health, especially sanitation, which follows the trend of minimal support for environmental health by the Ministry of Health (Harpham & Few 2002). In 2003, only 0.12% of the Ministry of Healths operating budget went toward environmental health and sanitation (Tanzania Ministry of Health 2003). One crucial policy change implemented by the DUHP was free-of-charge care for at-risk populations. All fees for treatment, services, and medications are withheld for patients who are under five, expectant mothers, elderly and poor, or members of a vulnerable social group. In addition, patients with mental disorders or have specific diseases (i.e., HIV, TB, etc.) receive care free-of-charge. Waivers may be submitted by individuals who do not automatically qualify for
20 | P a g e
fee exemption under these categories. This policy only applies to the public healthcare facilities, but it is a step toward increasing access to healthcare for specific populations across the country.
5. Under-five diarrheal illness Children under-five are the most susceptible to certain diseases such as respiratory infections and diarrheal disease, and these illnesses present themselves much more severely in children. Several studies on under-five health have been conducted in Dar and Tanzania. According to the 2004-05 Tanzania Demographic and Health Survey (TTDHS), malaria was found to be the leading reason for hospital visitations in Dar es Salaam, followed by pneumonia, and then diarrhea. Of the households surveyed in urban areas, 10% of children were found to have diarrhea in the two weeks before the survey. Most of these children were between 6-35 months old. Across the nation, 13% of children were reported to have diarrhea in the preceding two weeks. Interestingly, the study found no significant difference between children whose mothers have different educational backgrounds or between children who from households with different amounts of wealth. Mothers were also asked what treatment they sought for their childs diarrhea. Of the mothers surveyed, 47% took their children to a health care provider, but home remedies were common as well. However, while 97.3% of mothers knew about oral rehydration salt (ORS) treatment, only 70% of children sick with diarrhea were given some form of ORS. Children were given pills or syrup for diarrhea in 40% of cases, which the WHO strictly recommends against, unless the diarrhea is suspected to be due to dysentery or cholera. The handbook on treatment of child diarrheal illness also recommends that mothers continue to feed children normally and increase fluid intake when children are sick (WHO 1993). These methods prevent children from becoming dehydrated and help children retain micronutrients that are lost during diarrheal
21 | P a g e
episodes. In Tanzania, the TTDHS found that 24% of children were offered somewhat less or much less fluids than usual, and that 49% of children were given somewhat less or much less food. These unsafe practices are the proximate causes of children becoming severely dehydrated or malnourished. In the district of Ilala, where two of the three communities in this study was located, Kulwa et al. (2006) conducted 100 household surveys and found that 80% of the children had been sick at some time in the 7 days before the survey was conducted. The high rates of childhood morbidity resulted primarily from malaria with fever (40%), diarrhea (35%), and choriza (cold; 25%). Over the course of a year, each child had reported an average of five episodes of diarrhea (defined as three or more loose stools within 24 hours). Diarrheal episodes accounted for 23% of pediatric admissions at national-level referral hospitals at the time of the study. 3 Frequent diarrheal episodes affect physical growth patterns and prevalence of malnutrition. Kulwa et al. (2006) reported data that showed a negative correlation between growth stunting and the age complementary foods/fluids were introduced. Complementary foods may introduce foreign microorganisms to an infant, which could lead to diarrheal illness, and if not treated, dehydration. Of children they encountered, 11% were severely malnourished. In another study in Tanzania, 40% of under-fives were abnormally short for their age (International Food Policy Research Institute 2002). Intrauterine growth retardation may be one contributing factor. Interestingly, cultural factors may exacerbate child health problems. Kulwa et al. (2006) found that elders in Tanzanian coastal communities, such as urban Dar es Salaam, generally advise pregnant women to eat less food to avoid having too big of a baby that will cause
3 Statistics on incidence of diarrheal illness obtained from national-level referral hospitals (Mwananyamala, Ilala, and Temeke) from Jan. 2005-June 2008 are discussed below.
22 | P a g e
problems during childbirth. No data exist on how widely this flawed advice has been propagated, but education on pre-natal maternal nutrition may need to be incorporated into preventive programs. Prevalence rates of infant and child malnutrition could be decreased if mothers attended maternal and child health clinics and health professionals provided appropriate child nutrition information.
6. District hospital records of diarrheal illness Hospital records collected from all three district-level public hospitals, Mwananyamala, Amana, and Temeke, can give a better description of the burden of diarrheal illness on the under-five population in the city. Community-level dispensaries typically refer patients to these district-level referral hospitals when they see patients who are severely dehydrated. There are private hospitals in Dar es Salaam as well, but because they cost much more, indigent patients will only go to private hospitals if public hospitals are not able to provide the services they need. These private hospitals see upper-middle or upper class patients, and because acute diarrheal episodes disproportionately affect poor populations, the private hospitals see very few cases of child diarrhea. If they do, the cases are relatively mild.
23 | P a g e
Source: HMIS offices of Mwananyamala, Amana, Temeke. Obtained July-August 2008 * Missing data because past researcher borrowed record book and did not return ** Missing number of total under-five patients seen in outpatient ward *** Percentage calculated without Amana 2008 numbers
Table 1 provides an overview of the total number of under-five patients seen in outpatient clinics or admitted into the pediatric in-patient wards who were diagnosed with diarrhea for the period between January 2005 to June 2008. The numbers and percentages show considerable variation between hospitals and across years. Differences may be correlated with Table 1. Under-five patients at National District Hospitals in Dar es Salaam: Diagnoses & Deaths Related to Diarrheal Illness (January 2005 June 2008) Hospital/Year Outpatient < 5 Diagnoses Inpatient < 5 Diagnoses Inpatient < 5 Deaths Mwananyamala Diagnosis of DI Total diagnoses Diagnosis of DI Total diagnoses Deaths due to DI Total Deaths 2005 12390 89556 468 5474 11 906 2006 * 0 0 0 0 0 0 2007 2155 33238 512 4872 34 621 2008 644 7282 179 1984 4 186 11.68% 9.40% 2.86% Amana Diagnosis of Diarrheal disease Total diagnoses Diagnosis of Diarrheal disease Total diagnoses Deaths due to Diarrheal disease Total Deaths 2005 9458 63647 725 5816 21 781 2006 12484 96212 946 7782 0 649 2007 6615 61028 1629 5127 53 496 2008 ** 2722 0 1065 3352 58 259 12.93% 19.77% 6.04% Temeke Diagnosis of Diarrheal disease Total diagnoses Diagnosis of Diarrheal disease Total diagnoses Deaths due to Diarrheal disease Total Deaths 2005 13427 104136 771 5009 46 531 2006 26149 131307 1046 5378 38 527 2007 13017 80605 896 5671 27 431 2008 5781 31315 420 2780 20 352 16.80% 16.63% 7.12% Grand Totals: 104740 698326 8657 53245 312 5739 Overall %: 14.62% *** 16.26% 5.44%
24 | P a g e
average household income level in each of the municipalities (e.g., lower income households in Temeke correlating with a higher incidence of diarrheal illness), or the amount and seasonality of rainfall (i.e., the 2005-2006 drought year brought an early end to the rainy season). Regardless of year or hospital, reported morbidity is much higher than reported mortality due to effective use of oral rehydration therapy (ORT) and intravenous fluids. Although the majority of the international health community has lauded ORT as one of the cheapest and most effective child health interventions, ORT is a cork stemming a flood: it treats the superficial wound while neglecting upstream factors such as sanitation, hygiene, and safe water.
D. Why preventive child health, maternal beliefs, and Dar es Salaam? Most studies on the role of self-efficacy, empowerment, and motivation in health behavior change have occurred in developed nations such as the United States. Previous studies on these subjects in the developing world have been related to maternal health or adherence to drug regimens such as antiretrovirals for HIV/AIDS. Other studies examining beliefs and behaviors in the developing world related to child health have examined curative elements. Preventive health has been noticeably neglected. This is the first study of its kind examining the relationships between these perceptions and preventive behaviors of mothers in Dar. In Dar, where Western medical care can be accessed at a neighborhood dispensary or district hospital, rates of under-five mortality are decreasing, and with it, deaths due to diarrheal illness are also going down. While the benefits of modern medicine should be lauded for their achievement in the child survival arena, incidence rates are still sky-high, and depending on regional and temporal factors, experience massive fluctuations. Diarrheal illness disproportionately affects young children, given its pathogenesis. The primary danger of diarrhea is dehydration and leaching of nutrients critical to development. Because the amount of water a
25 | P a g e
child can lose relative to an adult before the child experiences dehydration is much smaller, severe bouts of diarrhea can be much more dangerous if not treated. Similarly, chronic diarrhea in young children can lead to undernutrition, which, in turn, can stunt growth and inhibit mental capacity during this critical period of language and motor skills development. Preventive health measures proven to improve child health outcomes are crucial to decreasing the morbidity caused by childhood diarrhea. The million-dollar question is how to get caretakers to adhere to these practices. What are predictive factors of mothers more-likely to practice a certain behavior? What are the roles of public health education campaigns, and what is their impact, realistically? Maternal education has been proclaimed the single best indicator for child health outcomes. In most areas of the world, mothers continue to be the primary caregivers. Many hypotheses have been drawn as to why maternal education is so strongly correlated, one of which is that it serves as a proxy for income, household size, equitable gender roles, household decision-making ability, employment, social networking, and beliefs, such as the three examined through this research. Limitations in this study prevented exploration into this hypothesis, specifically, but speculation can be made that education would be positively associated with household income and employment; be negatively associated with the number of children a mother would have; provide greater opportunity for forming social networks instead of growing up knowing only the inside of a house; and increase likelihood of more equal gender roles in the household held by the maternal and paternal heads. These feedback loops would foster perceptions of self-efficacy and empowerment that may influence their childrens health. Child health also should be explored within the context of maternal empowerment in Dar. The influences of self-efficacy and empowerment would be interesting to examine in a city where there is such a high rate of domestic violence. According to the WHO Multi-country
26 | P a g e
Study on Womens Health and Domestic Violence against Women (2005), 41% of women in Dar (who have been married, have lived with a man, or have had a regular sexual partner) have experienced physical or sexual violence at the hands of her partner. Of those women, 60% never sought help because they thought violence at the hands of their husband or partner was normal or not serious enough to warrant attention. The 2005 National Strategy for Growth and Reduction of Poverty (MKUKUTA) Status Report, stated that 42% of men and 60% of women believed it was acceptable for a husband to beat his wife. This unexpected statistic comments on the male-dominated culture perpetuated in Dar and its pervasiveness. Subjugating females has further implications for intra-household dynamic and its effects on child health. The amount of control a woman feels she can have and how much decision- making power she feels she can exercise in her household is likely to yield different child health outcomes (Sethuraman et al. 2006). A woman with more control over economic resources is likely to spend more on her children and households basic needs, such as education, food, and health (Houggenheimer et al. 2003). Caregivers personal hygiene practices have been shown to influence child health outcomes (Stanton and Clemens 1987). In Dar, since mothers are the primary caregivers, their hygiene, sanitation, water treatment, and home treatment behaviors provide the first line of defense against child diarrheal illness. Many reasons have been offered as to why variation between caregiver practices exists: level of biomedical knowledge, resource limitations, socioeconomic status, erroneous beliefs, systemic problems. Specifically for caregiver preventive practices for diarrheal illness, resource limitations, children not complying with caregivers efforts, and caregivers forgetfulness were identified as barriers, whereas level of biomedical knowledge was not (McLennan 2000).
27 | P a g e
From a public health perspective, instilling knowledge is much easier than changing cultural values. Based on personal observations of public health education campaigns on campus and in the community, knowledge has often been addressed as a stand-alone solution. The reasoning behind education campaigns is that everyone thinks and acts logically, and if an individual is made aware of a risk factor, that person will attempt to mitigate the risk. This obviously is not the case the vast majority of the time, and groups in the U.S. are increasingly relying on models such as the health belief model or Banduras self-efficacy model (and others explained in the review of existing literature) to inform their programs. This shift in mindset should be extended to the developing world as well, taking into account the complex interactions between sociodemographic characteristics, knowledge, beliefs, and health behaviors explored here.
E. Methodology Review A review of methodology was conducted to compare the methods and materials used in this study with prior research. McLennan (2000) conducted a study similar to this one, in which 597 primary caretakers of under-five children in a periurban community in the Dominican Republic were interviewed via randomized household sampling. Respondents were asked about their knowledge, practice, and barriers against practicing four behaviors that would prevent childhood diarrhea: 1) purification of drinking water, 2) breast-feeding, 3) washing of childrens hands before a meal, and 4) use of shoes. Questions were open-ended, and survey enumerators transcribed all responses given by the caretakers. Andrzejewski (2005) examined factors influencing the knowledge of etiology of diarrheal disease, malaria, and respiratory illness of 2500 adult men and women in Ghana. Household, socioeconomic, health knowledge, environmental attitudes and awareness, and child health
28 | P a g e
characteristics were gathered. The value of these factors for predicting biomedical knowledge and belief in hygiene were analyzed using bivariate and multivariate methods, and results showed that maternal education, media exposure, participation in community organizations, and migrant experience were contributed to increased health knowledge. Kegler et al. (1999) researched the association between beliefs and behaviors of 332 primary caregivers practice to prevent their children from getting lead poisoning in an American Indian community in Oklahoma. Two-person teams visited each household with children six and younger and conducted household surveys with the primary caretaker, covering knowledge, health beliefs, attitudes, and behaviors relating to child lead poisoning. Multivariate relationships between beliefs (perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and self-efficacy) and five behaviors were assessed. Kegler et al. (1999) found that self- efficacy and perceived barriers were the factors most highly associated with preventive behaviors caregivers employed.
29 | P a g e
IV. METHODOLOGY This research was conducted using primary interview data collected July 9-21, 2008 in Dar es Salaam, Tanzania by a team of Tanzanians and Stanford University affiliates led by Dr. Jennifer Davis and Dr. Alexandria Boehm. Our team worked on an interdisciplinary microbiology-sociology project examining the efficacy of an educational intervention, as well as the relationships between water, child health, and sanitation.
A. Geographic Location This study was conducted in three wards 4 : Mburahati, Sitakishari/Majumbasita, and Kitunda. Mburahati is a national housing community and in the northernmost Kinondoni district of Dar es Salaam, which has a population of 21,608. Sitakishari/Majumbasita and Kitunda are in the centrally-located Ilala district, and have populations of 75,014 and 23,428, respectively (Tanzania Census 2002). Altogether, the populations of the three streets encompass
4 The terms ward and community are used interchangeably throughout this study.
30 | P a g e
4.3% of the 2.8 million residents in Dar. No households were interviewed in the southernmost Temeke district, due to logistical barriers of length of travel time.
B. Community Partners Community partners included a local nonprofit, Health & Environmental Rescue Organization (HERO); Muhimbili University of Health and Allied Sciences (MUHAS); and the Dar es Salaam Water and Sanitation Authority (DAWASA). DAWASA was relatively uninvolved, and MUHAS provided support for the microbiology aspect of the project. HERO worked exclusively on the survey component, which provided the data for this study. Prior to our arrival, HERO investigated communities we could work in, and three communities were randomly selected. Once selected, representatives from HERO cultivated relations in those communities. They spoke with the community leaders to gain permission, and once received, obtained maps for each of the three communities. Maps were important for locating houses on numbered plots of land that would be sampled. They were used by HERO field supervisors on interview days to direct survey enumerators. HERO also worked with community leaders to identify houses with children under the age of five. These houses were on numbered plots of land, and houses were selected to be interviewed by inputting the plot numbers into a Microsoft Excel application that randomly selected a specified quantity of plot numbers. HERO served as the human resources managers for the project. Given their experience with past projects and their networks with skilled labor pools, they recruited survey enumerators by publicizing the job availability mostly by word-of-mouth. Interested applicants attended the first training session, and they were interviewed and selected by the joint HERO-Stanford project team. After selection, HERO helped train the survey enumerators during the initial
31 | P a g e
three-week training session and during each of the three-day trainings in between the four surveys. Officially, they were the employers of the enumerators and served as the management team in the field, since as wazungu, or foreigners, the Stanford members of the research team did not want to have a visible presence in the communities and risk survey bias. In addition to these formal roles, HERO and MUHAS representatives acted as cultural brokers for the Stanford research team. They negotiated the terms of working within the communities where we conducted a trial run and where we actually conducted the study. Toward the end of the project, they were consulted about what an appropriate celebratory banquet would look like. For me, HERO provided a useful introduction to perceptions of health in Dar, the healthcare system in Tanzania, and organizations that were working on child and maternal health in Dar. Other individuals who helped me overcome regional and cultural barriers were Eddy Liuki, our hired driver, and Douglas Mushi, an assistant professor at a university in Morogoro who worked with us in the microbiology lab. .
C. Survey tool The survey tool was created during Spring Quarter 2008 on Stanford campus by a faculty-student team led by Dr. Jennifer Davis and Ph.D. candidate Amy Pickering. We used surveys from Dr. Davis previous studies, revised questions, coded them in The Survey System (TSS), and tested each individual section for logic problems. Survey components included: health, water sources, sanitation, social capital and economic information, hygiene, hand sampling, and water sampling. The entire survey tool was coded in late spring into TSS and was debugged for logic problems through the beginning of enumerator training.
32 | P a g e
The complete dataset on which this research draws consists of responses from households that responded to all of the four different surveys, ranging in length from 267-644 questions. The data from this project drew almost exclusively from the baseline survey, because this data likely included the least amount of respondent bias. Since respondent bias would increase over time with exposure to the research team, responses from the first visit were primarily used. However, some demographic data regarding treatment-seeking practices, home treatment of diarrhea, and under-five deaths in the family were taken from the third survey and were included in the descriptive results section. The third survey was conducted two weeks after completion of the first survey, in mid- to late- August. The sample size from the baseline survey was also greatest due to attrition from respondent fatigue after repeat visits. Casewise deletion of individuals who did not answer all of the questions used for analysis removed individuals for whom we have incomplete data.
1. Survey enumerator training Survey enumerators were hired to collect data and translate the survey. The survey enumeration position for this research project was advertised by HERO and MUHAS. Interested parties attended the first training day in June 2009. Stanford affiliates and HERO or MUHAS representatives interviewed the initial pool of thirty applicants. Two rounds of cuts were made, one immediately after the interviews based on qualifications and interest in the research, and one at the end of the three-week training period. The objective of the first round was to assess applicants ability to commit time to the position, interest in the research topic, past survey enumeration experience, and proper attitude toward the project (i.e., not participating just for the compensation). The second cut was made based on performance and skill as an enumerator. Those who made the first cut but not the second cut received
33 | P a g e
compensation for training. Twenty-three enumerators were selected based on the above criteria, taking gender balance into consideration. (Given the conservative gender roles in Dar, we anticipated that female respondents would be uncomfortable in a house alone with two men). These enumerators underwent three weeks of rigorous training to ensure quality of data collection. Trainings ran from 8:30am 4:30pm with three breaks in between, for morning snack, lunch, and afternoon snack. Training was held in the top floor of the Colubus Hotel in Dar, and each day consisted of learning or practicing interviews, translating and debugging the survey tool, learning about the research, or practicing water and hand sampling techniques (for the microbiology portion of the project). The second cut of applicants was decided during the last week of the three-week training. The HERO and MUHAS supervising team acted as potential interviewees and had each potential enumerator interview them. Enumerators familiarity with the questions, skill as an interviewer, and accuracy when inputting responses were evaluated. Performance during one trial run in a community was also taken into consideration. During this trial, a HERO supervisor or Stanford team member would accompany each enumerator pair and observe while interviews were conducted with maternal heads of household. The observer was there to provide technical support if the handheld personal digital assistants (PDAs) malfunctioned and to evaluate the interviewing technique and ability to establish rapport. Five of the 23 enumerators were not offered jobs, and 18 were hired to work full days Monday-Friday and half-day on Saturday. Sixteen would be conducting household surveys while two worked on environmental water sample collection for the microbiology portion of the larger project. Eight female enumerators and 10 male enumerators were hired, so each enumerator pair would consist of a member of each sex. Each of the 16 household survey enumerators were asked to list five co-workers of the opposite sex with whom they would like to work, and five individuals of the opposite sex with
34 | P a g e
whom they would not want to be paired. Taking these personal requests into account, the enumerator pairs were formed for the duration of data collection in the field.
2. Household surveys Overall, 334 interviews with maternal heads of households 5 were conducted in Kiswahili by the eight enumerator pairs in Mburahati, Sitakishari/Majumbasita, and Kitunda communities. Surveys were conducted at the households of the women being interviewed. One enumerator asked the questions, and the other enumerator inputted responses into handheld personal digital assistants (PDA). On the first day of entering a new community, each enumerator pair was given a list of land plot numbers and corresponding family names, since multiple families lived on a single plot of land or in a single house. These families all had children under the age of five and had been selected randomly. If the maternal head-of-household was not available, enumerators were instructed to skip the house and return at a later time or date. If the maternal head was available, the interview would proceed after she gave verbal consent. Enumerators were asked to avoid respondent bias by encouraging any hovering male to permit his wife to answer the questions herself. Because females are predominantly the primary caregivers in the house, their responses would likely be the most accurate reflection of household water, sanitation, and health.
5 For the purposes of analysis, a household is defined as a unit as consisting of the individuals living in the same house who the maternal head named as part of the family. The house is the physical structure in which the household lives. A maternal head does not signify a single-headed household, but is identified as the female head of the family. Maternal heads are most often the mother of children in the family, but they could also be grandmothers or older siblings.
35 | P a g e
3. Quality control Each night, data collected during the day was uploaded to a central data computer, and Amy Pickering and Dr. Davis would carry out cursory data cleaning. Questions about the data content, translations, and quality were answered by the survey enumerators the following morning. Thorough data cleaning was conducted October-November 2008 by Amy Pickering, undergraduate research assistant Kirsten Rogers, and Dr. Davis.
4. Language and translation The survey tool was translated into Kiswahili during the first week of survey enumerator training. Sections of the survey were divided up among five groups of enumerators working with one Stanford affiliate. Each group devised their own method for translation and transcription, and the Stanford affiliate served to ensure that the meaning of each question was understood correctly by the enumerators and that the questions intent was translated accurately. After completing translation, the entire survey was read through, question by question, with the entire group present. This served two purposes: 1) to cross-check and standardize groups translations and 2) to facilitate enumerators familiarity with the survey tool. For short answer responses to questions that we received in Kiswahili (i.e., specify other), we asked the enumerator pair the following day to translate the response into English.
D. Data analysis 1. Definition of variables Three beliefs or perceptions hypothesized to be associated with preventive behavior outcomes were assessed: self-efficacy, empowerment, and motivation. Self-efficacy, or the belief that one is capable of accomplishing a task (Bandura 1977), was evaluated by whether the
36 | P a g e
respondent agreed or disagreed with the statement, I can prevent my child from getting diarrhea. While self-efficacy focuses on perceptions and expectations, empowerment examines the ability to make choices in regards to resources, agency, and achievements (Kabeer 1999). In this study, empowerment was examined in relation to material resources, because as described above, womens decision-making ability on household expenses has been highly correlated with decreased child mortality. Empowerment was defined by the respondents alignment with the statement, I often make decisions on how to spend money in the household. Both self-efficacy and empowerment represent perceived ability, but motivation evaluates underlying sentiments of whether or not the respondent wants to improve the status quo. The best question in the survey to gauge motivation was asking overall, how satisfied the respondent was with her current sanitation situation. It was hypothesized that because such a large percentage of respondents believed that uncleanliness was a risk factor for childhood diarrhea, this motivation to improve sanitation may also experience a spill-over effect into hygiene, water treatment, and ORS use practices. Four preventive health behaviors were selected to represent a wide array of individual actions mothers could employ to keep their children from getting sick. These behaviors reflected four main categories of habits that public health campaigns encourage individuals to adopt: personal hygiene, sanitation, treatment of drinking water, and use of ORS for children with diarrhea. Personal hygiene was best represented by the mothers reported handwashing habits. Mothers were asked to list at what times during the day she typically washes her hands. A dummy variable scoring respondents from 0-3 was created. Respondents were given one point for each of the following times she reported washing her hands: after defecation, prior to
37 | P a g e
preparing food, and prior to eating. A stringent hygiene variable was created from this scoring rubric, in which mothers either handwashed at all of the three critical times or not. Sanitation was the only variable that was visually observed by the survey enumerators instead of depending on self-reported results. Enumerators investigated latrines at each of the households and recorded the presence or absence of feces around the toilet. Treatment of water used for drinking or cooking was assessed by asking respondents what methods they knew about for cleaning water, and in conjunction, which of those methods they used. Of the unprompted responses they gave, respondents were asked whether they always, sometimes, or rarely/never used that method to treat their own water. Filtering with cloth was a common response, but pathogens are small enough to fit between the threads, so it was discarded as an adequate water treatment method for removing microbes (Murcott 2006). Mothers were categorized as always boiling/chlorinating or not. Whether or not the mother prepared ORS (rice water, coconut milk, watery soup) at home the last time her child had diarrhea was used as the indicator for ORS use. Use of ORS is effective for preventing dehydration caused by diarrhea, which would ward off diarrheas most dangerous effects on young children (WHO 1993).
2. Statistical analysis Data was analyzed by descriptive, univariate, and multivariate methods using SPSS (Statistical Package for Social Scientists) 17.0 software. Descriptive results, portraying the sample populations socioeconomic background, maternal characteristics, and water, health, and sanitation practices were obtained through frequency analyses using SPSS. Characteristics supported by literature expected to impact behavior outcomes were selected to be included in univariate and multivariate models. It was hypothesized that these
38 | P a g e
characteristics may also be associated with the beliefs of self-efficacy, empowerment, and motivation examined in this study. The characteristics selected were: maternal education, maternal employment, maternal age, religious affiliation, home ownership, and number of families living in the same house as the respondent. Household income and expenditures were excluded because they correlated closely with the characteristics named above (p < .001, p < .001). Due to the sensitive nature and confusion regarding those particular questions, more respondents withheld responses, and inclusion of those variables would have diminished sample size by nearly 100 or 40, respectively. Chi-square tests were conducted to determine the directionality and unadjusted univariate relationship between behaviors and characteristics or beliefs. Strength of the relationship was determined by examining the p-values from chi-square tests and from 95% confidence intervals and odds ratios obtained from univariate binary logistic regression. Statistical significance was attributed to associations with a p-value < 0.05, and relationships with p-values < 0.10 were attributed marginal significance. Odds ratio and 95% confidence interval values were evaluated qualitatively and for directionality. Multivariate models were created using binary logistic regression, since behaviors were dichotomous variables (depending if the mother performed the behavior or not). Reduced models were created using stepwise binary logistic regression. Since the variables representing beliefs were also dichotomous and were hypothesized to be associated with maternal and household characteristics, binary logistic regression was also used to construct multivariate models for self-efficacy, empowerment, and motivation. Ordinary least squares regression was used to develop a multivariate model for the indicator for maternal knowledge of risk factors for childhood diarrhea.
39 | P a g e
E. Reporting of results One of the main reasons I am writing this thesis is because I hope it will inform future public health initiatives that seek to change health behaviors of mothers around the health of their young children. Although I realize that there are severe limitations to broader application of the results from this study beyond Mburahati, Sitakishari / Majumbasita, and Kitunda, this case study will add to the increasing body of literature on attitudes of self-efficacy, empowerment, and motivation with regard to health behavior. The organizations I will share a shortened version of this document with include: African Medical and Research Foundation Tanzania, Health and Environmental Rescue Organization, each of the district hospitals in Dar, and Students for International Change. I will also send the entire document to Muhimbili University of Health and Allied Sciences library, which features a wide range of theses that have been written on health issues in Tanzania and East Africa. Muhimbili is home to the largest teaching hospital in Tanzania, and MUHAS is its school of public health equivalent, so my work will be available to current students and faculty for reference.
40 | P a g e
V. RESULTS A. Descriptive results In total, 334 maternal heads of households with under-five children were interviewed, and 311 of those respondents were included in analysis. The households were distributed between the three communities fairly evenly, with 121 (36.2% ) surveys completed in Mburahati, 117 (35.0%) in Sitakishari/Majumbasita, and 96 (28.7%) in Kitunda. Each of these three communities had populations that exceed 20,000 individuals, so approximately 0.5% of the households were surveyed in each community. Since Mburahati is located in Kinondoni district, 36% of households surveyed were located in Kinondoni, while 63.8% were located in Ilala district. No surveys were conducted in Temeke district. Although all 334 interviews were completed, eight were interrupted during the first visit and were resumed at a later date. Each interview lasted between 21 and 177 minutes. A subset of descriptive characteristics collected through the survey is displayed in Table 2, and select data is described below.
1. Household characteristics A large proportion of Dar was built around squatters who emigrated from rural regions to the city, and as a result, much of the city is poorly planned and overcrowded. Of the respondents sampled here, 58% shared their house with at least one other family, and 42% of respondents rented the house in which they lived. The median number of individuals per family was five, with a standard deviation of 2.4 members, and the mean monthly household income
41 | P a g e
42 | P a g e
was US $176.83 6 (standard deviation of $162.62; 25 th percentile = $65.28 and 75 th percentile = $261.12). Due to the sensitive nature of this question and confusion that may arise if the household has no steady source of income, only 117 respondents provided a response to this question. Other measures of financial means were household expenditure and household assets. On average, households spent $29.22 each week. Respondents were asked if they owned a working radio (73.1%), refrigerator (26.6%), gas stove (2.7%), bicycle (22.2%), motorcycle (3.6%), or car/truck (6.3%). Christianity and Islam are the two major religions in Dar, due to its history of colonization by the English and commercial activities with Islamic nations. The study population reflected an even split, with 50.6% of respondents reporting an affiliation with Christianity, and 49.4% affiliating themselves with Islam. Since religion was removed from the national census in 1967, official government statistics on religion were unavailable to compare the proportion in our study population with city-wide statistics. However, NBS 2005 found that 30% of its sample population was Muslim, and 57.5% was Protestant or Catholic. In order to gauge respondents sense of community, respondents were asked how similar they felt their family was compared to other families around them. Results were as follows: 9% of respondents felt that their family was very similar to the families living around them, 20.7% felt somewhat similar, 33.5% felt somewhat different, and 32.6% felt very different.
2. Water and sanitation services Within the population surveyed, 48.2% of respondents acquired water from a private well (her own or her neighbors), 38.3% acquired water from a private tap (her own or her
6 Conversion factor of 1148.90 Tsh.: US $1.00 was found by finding the mean exchange rate between the dates this data was collected, from July 9 July 21, 2008.
43 | P a g e
neighbors), 22.2% used water from a public well, 14.1% got water from a mobile water tanker or cart vendor, and 3.3% used bottled water. No respondents reported using rainwater collection or collecting water from large bodies of surface water, such as rivers, ponds, or canals, which was different from the 8.3% of urban mainland Tanzanians who reported acquiring drinking water from these sources (NBS 2005). One in five mothers stated that she did not know of any ways to clean water before drinking or cooking. Boiling (70.4%), chlorine treatment (32.1), and filtering with cloth (18.6%) were the most-widely known water treatment methods. Of the respondents who knew about a certain water treatment method, responses of how frequently they used that method to clean water before drinking or cooking varied. Filtering with cloth had the highest percentage of respondents who used the method, out of those who said they knew about it (68.3%), followed by boiling (66.1%), and chlorinating (37.5%). No respondents knew about solar disinfection, only two respondents knew about using a ceramic/sand filter, and three knew about sedimentation as a water treatment method. When asked how satisfied her family was with the current water supply situation, just over half of mothers stated that they were dissatisfied. The time-consuming nature of water collection (30.5%), insufficient supply to meet needs (24.9%), heavy cost (12.6%), and poor quality of the water (8.1%) were cited as reasons for dissatisfaction. All respondents had sanitation facilities, but the quality and utility of these facilities differed between respondents. All respondents reported using the toilet when asked where members of her family generally went to the bathroom. When asked specifically about where their children defecate, the most common responses were: a potty or small training toilet bowl (60.2%), toilet in home (39.5%), diapers (8.7), and out in the open (7.5%).
44 | P a g e
Survey enumerators recorded observations of toilet features, which were used to infer practicality and quality of sanitation. Survey enumerators asked respondents for permission to examine the pit latrine, and 93.5% of respondents consented. Just under half of latrines had a roof, just over half had an improved pit or septic tank, three-quarters had a door, and nearly all toilets had a concrete slab floor. Enumerators then recorded the distance between the top of the latrine and the top of the level of feces. Out of 129 recorded observations, 57 had values of one meter or less. Respondents perception on the cleanliness, functionality, convenience, and privacy of their latrine were generally positive, with the lowest percentage of respondents rating her toilet as clean (54.5%). However, only one-quarter of respondents knew that their septic tank or latrine pit had ever been emptied. Of the individuals who had emptied their tanks or pits before, two-thirds did not know where their disposed waste went. Of those who knew where the waste went, 86.2% stated that their waste went into a new hole near the latrine, usually dug by paid workers who are cheaper than those who remove the waste from the house plot. A greater percentage of respondents were satisfied with their familys sanitation situation than those satisfied with their water situation (68% vs. 47%). Main reasons given for being dissatisfied were lack of privacy (25.6%), lack of cleanliness (24.5%), and a full pit or tank (14.2%). The top reason given for not improving her familys sanitation situation was because the family rented the house (39.3%) instead of owning it. When asked to rate the sanitation practices of households around their own, 16.5% of respondents rated their neighbors practices as good, 29.0% as fair, 17.4% as bad, and 37.1% did not respond.
45 | P a g e
3. Health of household and health practices On average, for the 114 mothers whose responses were recorded for both household income and health expenses, mothers reported that their family spent 7.1% of their household income on healthcare. Of the 46 who responded to the question about whether or not they had sought health care for a family member in the last two weeks, 34 went to a hospital, four went to a clinic, and eight went to a pharmacy. Of the 247 responses to this question, 15 respondents (6.1%) had experienced an under- five child death. Two of those mothers had two children die before the age of five. The causes of death were malaria (6 children), diarrhea (4), stillbirth (4), pneumonia (1), and unknown (2). This mortality rate of 61 per 1000 live births is about half the national rate of 112 deaths per 1000 live births (11.2%) or 110 deaths per 1000 live births (11.0%) in Dar (NBS 2005). Morbidity of an under-five child in the two days prior to survey administration was considerably high. Approximately 23% of respondents had a sick child. Where individuals get health information provides valuable data on what sources are most commonly-used and what methods are most effective for disseminating health messages. Responses did not reflect one or two overwhelming sources; 38.3% of respondents often received health information from health clinics, 23.0% often received it from radio programs, 18.3% often from TV broadcasts, and 18.7% often from medical professionals. Only 2.7% of individuals often received health information from an NGO staff member, and 12.7% of individuals sometimes did. Only 4.0% of respondents often or sometimes received health information from a traditional healer, and of 156 respondents who sought medical care the last time their child was sick with diarrhea, none of them reported going to traditional healers, which was different than what was found in studies conducted in rural Tanzania (Kayombo 2007).
46 | P a g e
4. Characteristics of maternal head of household The age of respondents ranged from 16 to 62, and the median age was 28. A smaller percentage of our study population (89.8%) had received some formal schooling than the percentage found by the TTDHS 2005 for Dar (92.4%). The percentage of individuals who had attended primary school (68.9%) as their highest level of education was approximately the same as the percentage the TTDHS found in Dar (67.1%). There was a very strong correlation between literacy or writing ability and formal education; the 11.1% who could not read, and the 11.4% who could not write closely mirrored the 11.2% of respondents who had no formal education. The proportion of respondents who worked outside the home was drastically lower than the citywide female employment percentage. At the time of the interview, 18.6% of mothers were employed, compared to a 45.5% citywide female employment rate (NBS 2005). Since only 0.9% of respondents here reported current matriculation in school, the primary occupation of the vast majority of respondents was caretaker of children and the home.
5. Maternal knowledge, beliefs, and perceptions A series of questions sought to understand the knowledge of childhood diarrhea etiology, perceptions of control, and degree that social networks influenced beliefs. The results of these questions are displayed in Table 2. Overall, respondents knew that germs were the main cause of illness, and the majority of individuals were satisfied with their water and sanitation situation. The study population exhibited opinions that would contribute to social norms promoting hygienic behaviors. Nearly 90% of respondents agreed strongly or somewhat that mothers who dont keep her children clean ought to be ashamed. There was a high awareness of germs being the cause of illness, and
47 | P a g e
as a group, respondents felt that their neighbors and families living nearby were dirty or at least dirtier than their own families. It would follow that the majority of respondents felt that it is normal for children to regularly get diarrhea and that the health problems of the respondents family are caused by uncontrollable elements. However, respondents were inconsistent with their perceived level of control when asked whether she believed she could prevent her children from getting diarrheal illness. There was significant correlation between respondents who believed they could prevent their children from getting diarrheal illness and those who believed her familys health problems were caused by thing she had no control over (p=.064) or those who believed it was normal for children to get diarrhea regularly (p=.079). Of note, citywide, 37.8% of women reported having joint- or sole-final say in decisions to make large purchases for her household, and 49.7% of women said their voice had decision- making weight in making daily purchases (NBS 2005). In comparison, the women in our study Table 3. Descriptive results of knowledge, attitudes, and perceptions of respondents Knowledge, Attitude, or Perception Strongly agree Agree somewhat Disagree Missing or DK N Social factors / influences My family is clean compared to other families. 49.1% 32.6% 12.3% 6.0% 314 A mother who doesn't keep her children clean should be ashamed 76.0% 12.0% 7.8% 4.2% 320 I think many households in this area are dirty 41.9% 20.7% 28.1% 9.3% 303 Only rich people wash their hands with soap 11.1% 7.2% 79.3% 2.4% 326 Perception of control It is normal for children to get diarrhea regularly. 49.1% 13.5% 36.2% 1.2% 314 I can prevent my children from getting diarrheal illness 57.5% 14.1% 26.6% 1.8% 328 My family's health problems are caused by things I have no control over 56.0% 13.8% 25.7% 4.5% 319 Knowledge Germs are the main cause of illness 87.4% 4.5% 3.0% 5.1% 317 Satisfaction We have enough water in our household for everyone to keep themselves clean. 63.2% 14.4% 21.9% 0.6% 332 My family has more important priorities than improving our sanitation 25.1% 16.5% 52.7% 5.7% 315 Overall, my family is satisfied with our current sanitation situation 67.4% 20.7% 10.8% 1.2% 330 Empowerment I often make decisions on how to spend money. 71.6% 8.1% 17.7% 2.7% 325
48 | P a g e
Figure 2. Theoretical model of relationships between factors influencing child health outcomes with relation to diarrheal illness population reportedly have more decision-making ability regarding household spending (79.7% strongly or somewhat agreed).
B. Univariate results
Out of 334 respondents, sample size was reduced to 311 during analysis due to incomplete surveys. A subset of 269 respondents was used to analyze relationships where the dependent variable was sanitation, since not all cases contained observations by enumerators for
49 | P a g e
this variable. Univariate analyses were conducted using Chi-square tests and the binary logit function with one input variable to determine the p-value, odds ratio, and confidence intervals for each relationship. The theoretical model explored in this study is shown in Figure 2. Social, economic, and cultural factors shape the landscape of beliefs and perceptions individuals may have. Past studies have suggested these factors are predictive of both preventive behaviors mothers report to perform and child health outcomes. They may also play a role in determining what information mothers receive from external sources about causes of diarrhea, which would, in turn, influence individual perceptions of health and efficacy. In the third tier of the model, both knowledge and beliefs are conjectured to influence reported and observed behaviors. Many public health campaigns inappropriately exploit the pathway linking knowledge and behaviors. One focus of this study was to examine a parallel pathway between individual beliefs/perceptions and preventive behaviors mothers report to use. The degree of association between beliefs and behaviors versus knowledge and behaviors was explored and results are reported in the following sections. Past studies have conducted more rigorous analyses that have supported the link between hygiene, sanitation, water treatment, and ORS use behaviors with child health outcomes. Ample literature exists regarding those relationships. As such, the association between behaviors and health outcomes was not investigated in this study.
50 | P a g e
1. Beliefs and knowledge vs. behaviors Table 4 describes the univariate associations between behaviors versus self-efficacy, empowerment, motivation, and knowledge. The self-efficacy column in Table 4 shows that all of the relationships between self- efficacy and the four behaviors exhibited positive directionality, with one relationship rising to marginal significance. With no other factors controlled for, respondents who expressed high self-efficacy were 1.642 times more likely than their counterparts to report always using proper water treatment methods (p=0.053). Other than this marginally significant result, both reported hygiene practices and ORS use were more than 1.5 times as likely to be practiced by individuals who believed they could prevent their children from getting diarrhea (p=.107, .117). The second column in Table 4 displays the correlation between empowerment and target behaviors. Empowerment was highly predictive for mothers use of proper water treatment methods for cleaning water for drinking or cooking (p < .001). The relationship between this perception and other behaviors showed no significant correlations. Examining the percentages resulting from a cross-tabulation in the motivation column of Table 4, it was inconclusive if respondents who were highly motivated to improve their sanitation situation were more or less likely to handwash at critical times, use proper water treatment technique, and prepare ORS for children. Respondents who expressed low motivation, or high satisfaction with their sanitation situation, were significantly less likely to have feces around their latrines. The fourth column in Table 4 shows that knowledge of risk factors for diarrhea exhibited negligible explanatory power with regard to reported and observed behaviors. For these relationships, p-values lied well outside intervals indicating significant relationships (p=.765, .785, .795, and .930).
51 | P a g e
2. Sociodemographic characteristics vs. behaviors Table 5 displays unadjusted univariate analyses of social, economic, and cultural factors in behavior outcomes. The first column in Table 5 lists hygiene as the dependent variable, and with this reported behavioral outcome, age of the respondent was the only relationship that rose to a statistically significant level (p < .017). However, with a coefficient of .034, there is not a large increase in likelihood of reported handwashing for each year the respondent ages. More characteristics were independently associated with sanitation (column 2 in Table 5) Literacy, ability to write, maternal formal schooling, and household expenditures were directly correlated with lack of observed feces, while maternal employment and Christianity were marginally associated in the positive direction. All of these characteristics, with the addition of whether the family has a source of emergency money, were shown to move in the same direction as reported proper treatment of water for drinking or cooking (column 3 in Table 5). Because literacy, writing, and formal schooling were highly associated, which of the three factors has the greatest influence is indistinguishable. Since literacy and writing are highly predictive of receiving some formal schooling (p<.001), in the multivariate analyses that follow, formal education was selected as the representative variable. The ORS use column in Table 5 exhibited a couple significant correlations with the characteristics analyzed. The number of families living in the same house as the respondent may be predictive of ORS use, as could whether or not the respondent had a source of emergency money that were not her own family members, though to a lesser extent. One characteristic that was closely associated with all of the behaviors was religious affiliation. Christianity was positively predictive for utilizing self-reported water treatment
52 | P a g e
methods (p < .001) and marginally significant with relation to observed feces around the latrine (p=.065). Although the relationships between religion and reported hand hygiene, and between religion and ORS use did not reach statistically significant levels (p =.106, p = .173), the results were skewed toward Christians being more likely to report performance of these behaviors. The role of community in shaping these differences was also explored, since differences in community composition, social norms, and environment may serve as confounds. In Mburahati, 55.9% of respondents were Muslim, and 59.3% of respondents in Kitunda were Christian. Kitunda had significantly more homeowners than Sitakishari or Mburahati (78.0% vs. 44% and 55%, respectively), and Kitunda had more single-family homes than either of the other communities (73.6% vs. 24.8% and 39.6%, respectively). Communities were not significantly correlated with behavior outcomes other than ORS use (p = .032), with a greater percentage of Kitunda respondents reporting use of ORS than in the other communities.
53 | P a g e
Table 4. Distribution of preventive behaviors relating to childhood diarrhea by belief / perception Self-efficacy Empowerment Motivation Knowledge Behavior High Low p- value OR (95% CI) High Low p- value OR (95% CI) High Low p- value OR (95% CI) p- value OR (95% CI) Hand washing N=311 41.0% 31.0% 0.107 1.548 (.909, 2.638) 39.2% 33.9% 0.461 1.256 (.684, 2.307) 65.3% 39.9% 0.38 1.250 (.760, 2.057) 0.765 1.037 (.817, 1.316) (No handwashing) 59.0% 69.0% 60.8% 66.1% 34.7% 60.1% No visible feces N=269 65.3% 56.2% 0.168 1.469 (.849, 2.541) 62.6% 65.9% 0.643 .852 (.432, 1.680) 45.3% 71.0% <.001 2.956 (1.738, 5.028) 0.785 1.037 (.801, 1.342) (Visible feces) 34.7% 43.8% 37.8% 34.1% 54.7% 29.0% Water treatment N=311 56.4% 44.0% 0.053 1.642 (.992, 2.720) 58.0% 30.4% <.001 3.173 (1.704, 5.908) 51.0% 54.0% 0.626 1.127 (.698, 1.819) 0.795 .970 (.768, 1.224) (Inadequate water treatment) 43.6% 56.0% 42.0% 69.6% 49.0% 46.0% ORS Use N=311 26.4% 17.9% 0.117 1.653 (.879, 3.108) 23.5% 26.8% 0.606 .841 (.435, 1.625) 21.4% 25.4% 0.452 1.245 (.702, 2.208) 0.93 .988 (.753, 1.296) (No ORS use) 73.6% 82.1% 76.5% 73.2% 78.6% 74.6%
54 | P a g e
Table 5. Chi-square univariate analyses of behaviors vs. sociodemographic characteristics and beliefs
7 Work and empowerment are significantly associated (p =.001). 96.6% of women who work reported sometimes making decisions on household spending.
55 | P a g e
C. Multivariate Results As shown above in the univariate analyses, multiple characteristics and beliefs appear to be associated with reported and observed preventive health behaviors. Models including all characteristics and beliefs were created using multivariate analyses for reported or observed performance of the four preventive behaviors: handwashing at critical times, no observed feces around the latrine, proper treatment of drinking water, and ORS use when under-five child last had diarrhea. Since all four of the behaviors are dichotomous, binary logistic regression models were used for each of the models shown in Table 6a. The reduced model of each of these behaviors is shown in Table 6b. In addition, multivariate binary logistic regression facilitated creation of models for each of the three beliefs and for the knowledge indicator, which are upstream factors for reported behaviors. These models are exhibited in Table 7.
1. Multivariate binary logit analyses of reported and observed behaviors Overall, 38.3% of the 311 respondents included in analysis reportedly washed their hands at critical times, 53.1% of respondents said they properly treated drinking/cooking water, 54.3% had no feces around their latrines, and 24.1% reportedly used ORS when their under- five child had diarrhea. There was a fair amount of variation within each of the indicators, and sample size was large enough to exhibit adequate statistical power. Thus, multivariate binary logit analyses could be constructed with a robust level of confidence. Model 1a in Table 6a quantitatively describes contributions of social and economic characteristics, knowledge, and beliefs toward reported handwashing at critical times. After adjusting for all other variables, greater maternal age remains significantly correlated with reported handwashing (p=.016). Contrary to predicted direction, lack of formal education is
56 | P a g e
positively and marginally influential in predicting this particular behavior outcome (p=.083). Christianity is also slightly predictive of positive reported handwashing practices, though values do not reach statistical significance (p=.122). High self-efficacy proves to be influential as well (OR=1.614, p=.096). Of note, knowledge, employment, and empowerment exhibit minimal explanatory power. However, this model only explains 5.3% of variance. The reduced model results shown in Model 1b in Table 6b support the findings in the non-reduced model. In this model, Christianity, lack of formal education, and high self-efficacy are found to exhibit similar associations with reported handwashing, while increased age of the respondent continues to exhibit the most robust correlation. A second model, Model 2a in Table 6a, describes the sanitation indicator of visible feces around the latrine pit. This model has more than double the explanatory power of the first model (Cox & Snell R 2 =.118). The regression results support the positive role of formal education with positive health behaviors (p=.098). Formal education beyond primary education, maternal employment, and high self-efficacy have odds ratios around 1.5. Age was marginally significant, though the correlation coefficient of .032 indicates that each year the respondent ages has minimal influence on observed outcome. Christianity also has marginal significance in the non-reduced model, which, in the reduced model (Model 2b in Table 6b), is shown to exhibit significant association at the 0.05 level. In both the reduced and non-reduced models, the individuals who were reportedly satisfied with their current sanitation situation were highly likely to have no feces around their latrines. Model 3a in Table 6a examines reported proper treatment of water for drinking or cooking. The explanatory power of Model 3 (R 2 =.108) is similar to that of Model 2. Maternal empowerment appears to be the biggest contributor to this specific model (p=.006), which is rivaled by religion in the reduced model (Model 3b in Table 6b). Of the four reduced or non-
57 | P a g e
reduced models, this is the only one in which maternal employment reaches levels of statistical significance in its contribution to the regression model (p=.046). With water treatment as the predicted outcome, the reduced and non-reduced models produced here reveal nearly-identical contributions by three variables: maternal employment, Christianity, and maternal empowerment. The reduced model suggests that formal schooling has a positive impact on proper water treatment, and that the number of families living in the same house is inversely related to reported water treatment. The last regression, Model 4a, had the least explanatory power (R 2 =.036). It has the fewest number of possible variables contributing to the outcome of making ORS at home when an under-five child had diarrhea. Most notably, having fewer number of families living in the same house is predictive for greater ORS use. High self-efficacy in the reduced and non- reduced models appears to have some positive association with the use of ORS. To summarize, these multivariate logit analyses showed that high self-efficacy was positively associated with all four behaviors, with a marginally significant association with reported handwashing. High maternal empowerment was only significantly associated with proper treatment of water in the positive direction, and interestingly, was a minor risk factor for increased feces observed around the latrine. Motivation did not have any significant correlations with three of the behaviors; not having feces around the pit was closely associated with satisfaction with the respondents satisfaction with the sanitation situation. Knowledge of behaviors or conditions that may cause diarrhea contributed very minimally to the four models described above.
58 | P a g e
2. Multivariate binary logit analyses of beliefs, perceptions, and knowledge Determinants of maternal beliefs and perceptions were modeled in Table 7. Model 5 shows that formal education has the greatest association with sentiments of self-efficacy, in particular, formal education beyond primary school. Empowerment is modeled in Model 6, and reveals a more complex role of multiple contributing factors. Nearly all of the social, economic, and knowledge factors are related to maternal empowerment in the expected direction, with the exception of home owning and the number of families living in the same house. Respondents who have more formal education, are employed, are older, or have greater knowledge of diarrhea risk factors are more likely to have some decision-making power over how her household spends money. Model 7 was similar to Model 5, in which there appears to be only one significant variable. In the case of the measurement for motivation used here, home owners are .789 times more likely to be satisfied with their sanitation situations.
59 | P a g e
Table 6a. Determinants of reported preventive behaviors for childhood diarrhea
Model 1 Handwashing at Critical Times N=311 Model 2 No observed feces around latrine N=269 Model 3 Proper Treatment of Drinking Water N=311 Model 4 ORS Use when Under-5 Child has Diarrhea N=311 Independent Variable OR 95% CI Sign. OR 95% CI Sign. OR 95% CI Sign. OR 95% CI Sign. Social & Economic
Home owner=1, renter=0 0.857 (.477, 1.540) 1.066 (.554, 2.049)
1.188 (.655, 2.154) 0.942 (.483, 1.835)
# Families in house (log) 1.19 (.833, 1.700) 0.896 (.601, 1.336) 0.878 (.613, 1.258) 0.647 (.424, .987) ** Knowledge of etiology of diarrhea (%) 1.001 (.739, 1.356) 1.096 (.775, 1.55) 0.887 (.656, 1.200) 1.039 (.740, 1.459)
Beliefs
I can prevent my child from getting diarrheal illness 1.614 (.918, 2.836) * 1.463 (.804, 2.664)
1.353 (.784, 2.332) 1.663 (.863, 3.205) I often make decisions on how to spend money in the household 0.981 (.500, 1.922) 0.574 (.266, 1.242) 2.592 (1.310, 5.130) 0.006 0.808 (.389, 1.676)
Overall, I am satisfied with my household's sanitation situation 1.378 (.815, 2.311) 2.793 (1.594, 4.895) *** 1.096 (.654, 1.839) 1.181 (.653, 2.137) Cox & Snell R Square 0.053
0.118 0.108
0.036
Log likelihood 396.834
321.211 394.342
332.348
Number of observations 311
269 311
311
*** = p<.001, ** = p < .05, * = p < .10, = p < .15
60 | P a g e
Table 6b. Determinants of reported preventive behaviors for childhood diarrhea, reduced models
Model 1 Handwashing at Critical Times N=311 Model 2 No observed feces around latrine N=269 Model 3 Proper Treatment of Drinking Water N=311 Model 4 ORS Use when Under-5 Child has Diarrhea N=311 Independent Variable OR 95% CI Sign. OR 95% CI Sign. OR 95% CI Sign. OR 95% CI Sign. Social & Economic
No education (No = 1, Yes = 0) 0.532 (.246, 1.152) 2.277 (.947, 5.472) * 1.747 (.778, 3.921)
---
Beyond primary education ---
---
---
---
Respondent's employment ---
---
1.902 (1.002, 3.610) **
---
Age of respondent 1.033 (1.005, 1.062) ** 1.032 (.998, 1.066) * ---
*** = p<.001, ** = p < .05, * = p < .10, = p < .15
61 | P a g e
*** = p<.001, ** = p < .05, * = p < .10, = p < .15 Table 7. Determinants of maternal beliefs and perceptions
Model 1 Self-Efficacy N=311 Model 2 Empowerment N=269 Model 3 Motivation N=311 Independent Variable OR 95% CI Sign. OR 95% CI Sign. OR 95% CI Sign. Social & Economic
0.878 (.609, 1.264) Knowledge of etiology of diarrhea (%) 1.143 (.825, 1.583) 1.515 (1.008, 2.277) ** 0.89 (.653, 1.212) Cox & Snell R Square 0.037
0.138
0.035 Log likelihood 350.976
247.118
376.377 Number of observations 311
311
311
61 | P a g e
VI. DISCUSSION The findings here suggest that although the beliefs examined were associated with certain behaviors, the relationships between beliefs and the outcomes in question are heterogeneous, complex, and have a high level of interaction with social and demographic characteristics. Unlike previous studies that have found beliefs of self-efficacy or empowerment can robustly predict child health outcomes or performance of desired behaviors (Kegler et al. 1999; Dearden et al. 2002; Tolhurst et al. 2008; Hendrickson et al. 2002; Sethuraman et al. 2006), the results reported above do not indicate any one factor being the most predictive of optimal behaviors. Instead, an intricate combination of factors associated to various degrees contributed to the outcomes under examination. Certain variables, such as self-efficacy and religion were positively associated with all reported outcomes, while others such as level of knowledge about risk factors for diarrhea, were not associated with any reported behaviors. Other variables, such as maternal education and empowerment, were correlated with certain outcomes in a direction different than their correlation with other behaviors. Thus, performance of behaviors known to
62 | P a g e decrease incidence of childhood diarrhea is associated with a multifaceted network of beliefs, individual experiences, and demographic attributes that reflect the complexity within these womens lives. This suggests that any effective community-based health behavior promotion program will need to be flexible and attentive to the variety of factors weighing in on health behavior change that are specific to the type of behavior change desired and the socioeconomic characteristics of the target population.
A. Key findings 1. Evaluating the role of self-efficacy Self-efficacy has been championed as a critical component in many health behavior change models, such as the health belief model and Banduras self-efficacy model (Bandura 1977; Elder et al. 1999). These models have been tested and modified within the context of developed-world health issues, but not as considerable a mass of literature exists regarding self- efficacy in the developing world. In many developing countries, maternal heads are the primary caretakers of the children and would have the greatest contact with under-five children. A mother balancing competing responsibilities would need to triage her priorities. Like any other person making decisions under conditions with limited resources, she would place more importance on the behaviors she felt would have the greatest impact. For these reasons, in this study, high self-efficacy of maternal heads was hypothesized to have a positive influence on reported health behaviors. The results shown here support this hypothesis and indicate that self-efficacy is positively correlated with reported performance of hygiene, sanitation, water treatment, and
63 | P a g e palliative behaviors, but its explanatory value is not as high as the specific demographic characteristics of age, education, and religion. As described above, nearly three-fourths of respondents believed that they could keep their children from getting diarrheal illness. Multivariate analyses reveal that after controlling for all other social, economic, and knowledge factors, respondents were more-likely to report performing all of the preventive health behaviors examined here. However, a model including only self-efficacy did not have as much explanatory power as one including the mothers age, education, and religion. This finding differs from past studies that concluded that increasing self-efficacy would most-consistently increase preventive behaviors women use to protect their children or themselves from health risks (Jirojwong and MacLennan 2003; Kegler et al. 1999). Several explanations may explain the discrepancy. The Jirojwong and MacLennan (2003) study focused secondary prevention behaviors 8 that women performed that would benefit them directly, breast screenings. The sample size was smaller and participants were recruited using a snowball- sampling method, which may generate bias in the sample population if the women identified through personal contacts and key persons were those who had stronger social networks and may perform behaviors as a result of positive social feedback. The findings in Kegler et al (1999) were similar to the study here in sample size and primary preventive behaviors assessed. However, the study was conducted in the United States, where more resources exist to reinforce positive behaviors. In Dar, environmental health is critically neglected and women do not have as many infrastructural resources as women in the States. Sentiments of self-efficacy may not be
8 Primary prevention behaviors are those further upstream to prevent the incidence of disease; secondary prevention behaviors defined as disease treatment and screenings; and tertiary prevention behaviors are rehabilitative and serve to manage the occurrence of disease.
64 | P a g e as influential as education, which, of its many benefits, would increase womens abilities to learn about and critically examine their options. Informal education, gained through the years, may have a similar influence. A multifaceted explanation incorporating self-efficacy, though not to the extent found in previous studies, may be appropriate for predicting performance of primary preventive behaviors in developing nations. The interaction between the behavioral outcomes and other upstream factors complicates the relationship between self-efficacy and the behaviors, and it brings into question the relative impact of self-efficacy. In every model, although self-efficacy was substantively significant in predicting reported or observed behaviors, other demographic characteristics were shown to exhibit greater contributions to the models explanatory power. With handwashing, the age of the respondent was more predictive. With regard to sanitation, religion, education, and age were more significant. For water treatment, employment and religion were more-highly associated. And with relation to use of ORS, the number of families in the house (or the economic level of the family) held greater significance. One trend, explained in a later section, is that knowledge of risk factors for diarrhea is not predictive of any of the desired behavioral outcomes. This suggests that mothers who believe they can keep their children healthy are more- likely to report performing behaviors that can prevent childhood diarrhea, even if they do not have accurate knowledge of what risk factors are for diarrhea. Understanding the demographic characteristics associated with self-efficacy may help explain the more complex relationships observed in this study that were not revealed in previous studies examining self-efficacy, such as the qualitative study conducted by Dearden et al. (2002). In this study, self-efficacy was found to be the differentiating factor between doers and
65 | P a g e nondoers of behaviors that would decrease child health risk to diarrhea. However, that study was conducted using semi-structured interviews, which, researchers admitted, provided limited sociodemographic information. Unaccounted-for confounds may have influenced their results. The research reported here created a logit model with self-efficacy as the dependent variable, and sociodemographic information as independent covariates. The resulting model showed education as the only factor that exhibited an important relationship, specifically, formal education beyond primary levels.
2. Evaluating the role of empowerment Findings here show that mothers with decision-making ability report better water treatment behaviors, but report no other significant correlation with other outcomes in question. This goes contrary to the plethora of recent literature that cites maternal empowerment, evaluated by decision-making power within the household, as a key factor in improved health behaviors (Franckel & Lalou 2008; Sethuraman et al. 2006; Tolhurst et al. 2008; WHO CSDH 2008). Even within Tanzania, the TDHS 2005 found that decreased under-five mortality was strongly associated with increased maternal participation in household decision-making. In a study conducted in Bagamoyo district, directly north of Dar, Mtango et al. (1992) reported that mothers with sole decision-making ability were significantly less likely to have her child die before the age of five. Results here suggest that the linkages between maternal empowerment and the majority of desired preventive health outcomes are more intricate than currently hypothesized. Previous studies mostly examined the pathways leading to the treatment of disease: when the child is sick,
66 | P a g e what factors into whether the mother seeks treatment? In the instances examined here, the child is not sick. The influences determining performance of the primary preventive behavior would be expected to be different, and perhaps more complex, since the relative importance of a certain behavior is left more to interpretation. The mother may only assert her power in instances she is sure her intervention would make a difference in the health outcome. Other social and cultural factors would be expected to influence this perception. For the multivariate logit model examining water treatment outcomes, which was the only model that had any level of significance with empowerment, several sociodemographic characteristics carried considerable weight. Employment, religion, and empowerment were all shown to be intricately linked, and in the models analyzed, it was very difficult to tease out which of the factors explained most of the variance. For example, employment was significantly associated with empowerment (p<.05). This finding was similar to that found by Daniels et al. (1990), in which the impact of latrines on childhood diarrhea in Lesotho was mediated by maternal work outside the home. In Dar, since boiling is the most common water cleaning method known and used by women in the study population, one explanation for this finding is that mothers with decision-making power are more likely to purchase sufficient charcoal to boil water. Unlike the findings of Sethuraman et al. (2006), in which sociodemographic factors carried the least explanatory power, the result of a multivariate logit regression examining empowerment links this perception very closely with upstream characteristics. Model 6 examines the factors contributing to empowerment, and it was the most robust model of the three beliefs. The model showed that in addition to employment, all else held constant, education, age, home
67 | P a g e renting, and knowledge contributed to increased reports of household decision-making. Lack of formal education may be related to empowerment, because women without any years of schooling may be from lower economic backgrounds and would likely have fewer opportunities or choices. Women without the opportunity for formal education may have grown up in households where they did not receive sufficient individual support or encouragement for a variety of reasons. Results here show that other forces are also at play, such that older women are significantly more-likely to make household decisions than their younger counterparts. Age was associated with empowerment in an unexpected direction. Due to the conservative gender roles in Tanzania, it was hypothesized that older women would be less likely to feel comfortable expressing opinions regarding household expenditures. Especially as Dar becomes more Westernized, due to trends in other urban areas, younger women might be more attracted to the ideology of gender equality. The opposite trend was found in this study. The pattern of older women expressing greater decision-making was also observed in tribal and rural women in India through structured interviews (Sethuraman et al. 2006), but no explanation was given. More research should be conducted to examine the perception of gender roles in older and younger women and men to interpret this result more conclusively.
3. Evaluating the role of motivation The measure for motivation was shown to only be strongly correlated with the respondents household sanitation situation, and because many other sociodemographic characteristics were also associated with household sanitation, this suggests a model similar to
68 | P a g e the one hypothesized above. In developed countries, health motivation has been shown to be positively correlated with performance of more health behaviors, especially in individuals with low health status (Moorman and Matulich 1993). Moorman and Matulich (1993) also found that the relationship between motivation and behaviors was intricate. They explain that the impact of motivation varies by the type of health behavior and the ability to perform the behavior, which is modulated by various sociodemographic factors. In this study, it was hypothesized that low satisfaction with current sanitary conditions may motivate individuals to perform individual behaviors to improve health outcomes. This reasoning was additionally justified by the observation of a large proportion of respondents believing that germs cause illness, and that dirty water and poor personal hygiene can cause diarrhea. However, results presented here suggest that the indicator of satisfaction level with sanitary conditions served purely as an indicator of contentment with sanitation, since individuals with no visible feces around their toilets were highly likely to report overall satisfaction with her sanitation situation. This measure of motivation was not correlated with any other behaviors; in fact, any slight directionality observed was the opposite trend predicted.
4. Evaluating the role of education vs. knowledge of risk factors Maternal education has been robustly associated with child health outcomes, and after considerable research, education has been shown to be one of the most common and most robust predictive factors in child health (UNICEF 2008, White 2005). Although this study examines the performance of behaviors known to improve child health, maternal education was shown to be predictive of increased performance of all behaviors except reported handwashing.
69 | P a g e Since previous studies would lead one to hypothesize positive correlation between handwashing and maternal education, this was an interesting and unexpected finding. The models created for this study cannot explain this result, and other sociodemographic factors that were not captured by the analyses shown above may increase understanding of this observation. In addition to being associated with three of the four behaviors, education was shown to be an influential upstream factor in self-efficacy and empowerment. Reasons why education would be so closely correlated with these outcomes include greater access to health information (UNICEF 2008; though the assessment of the role of health knowledge in this study shows that it may not be as impactful as previously acknowledged), exposure to new ideas and ways of thinking, and proxy for household income. Primary school education is free in Tanzania, so girls frequently receive at least some primary education, unless there are extenuating circumstances at home, and they are needed by their mothers to help care for a large number of younger children. Rates of matriculation in secondary school drop precipitously from primary school rates, since education beyond primary requires school fees. In families with limited resources, boys are given preference when it comes to higher education. This occurs for many reasons, a couple of which are: girls are needed at home to help with chores, and the common opinion is that educational investment in boys is more secure than in girls, since girls are more-likely to get married and become responsible for children (UNICEF 2001). The respondents who were able to receive some formal education had a greater likelihood of having higher self-efficacy and empowerment perceptions, and receiving schooling beyond primary levels, had an equally large effect in increasing these perceptions between women who had only primary education versus those who received more education.
70 | P a g e Knowledge of risk factors for diarrhea showed a negligible correlation with all behaviors and beliefs except empowerment, which contributes to the growing literature showing that knowledge without the additional support of self-efficacy or empowerment is not adequate for health behavior promotion. Older studies recommended education as an effective intervention (Bilenko et al. 1999; Esrey et al. 1991), but current theories of health behavior change discourage implementation of health promotion programs that unilaterally aim to educate around a specific health issue (Elder et al. 1999). The results here suggest that the efforts of public health campaigns to increase awareness of risk factors for diarrhea have less of an influence on reported performance of preventive behaviors than if the mother receives schooling. Not unlike many challenges faced by public health campaigns in the United States, increasing knowledge alone is not sufficient for motivating and reinforcing positive health behaviors.
5. Evaluating the role of religion Another surprising correlation reported above was the strong, unidirectional correlation between religion and behaviors in question. This finding correlating religion with health outcome was also pointed out by Asnake et al. (1992) when examining diarrheal incidence in Ethiopia. The results from the multiple regressions here showed that for this particular sample population, Christians were more-likely to report preventive behaviors than Muslims, when all else was held constant. It should be noted that this finding does not imply that one religious group intrinsically is more-likely to perform health behaviors over the other; it is highly probable that other sociodemographic characteristics and/or belief and values systems are asserting considerable influence.
71 | P a g e There is a growing amount of literature assessing the relationship between religion and health outcomes, but the vast majority of research has been conducted on the role of religion in individuals reactions to stressors or with regard to mental health (Ellison 1998). Nearly all research on this linkage has also been in developed countries, where the religion in question is Christianity versus no religion, such as the study conducted by Benjamins (2005). One study examining the role of Islam in preventive behaviors focused on smoking in Pakistan (Hameed et al. 2002), but it was not very rigorous and did not control for education or other variables. Since no literature was found on religions effect on the preventive behaviors in question, liberties were taken with contextualizing religion within the complex web of interactions between sociodemographic factors and individual beliefs. When examining religion within this context, environmental characteristics were first considered to be driving the variation observed. It was found that none of the three communities were heavily skewed in having more Christian or Muslim respondents, so the influence of community in driving the difference with regard to religion was ruled out. Results from a linear regression of religion versus reported household expenses showed that there was no significant difference (p=.725). There were very few Muslim respondents who reported receiving education beyond primary school. About the same percentage of individuals within each religious category received some formal education, but Christian respondents were almost three times more likely to attend school beyond primary levels. Given this observation, there may not have been a large enough subsample size to tease out influence of education. A greater percentage of Christian respondents was found to work outside the home and thus were more-likely to be generating income than Muslim respondents. However, since the regression analyses hold all of these
72 | P a g e variables constant and the variation between the two groups was still significant, the data suggests that other confounding factors may be playing a role. Further investigation into the social atmosphere of each of the communities and the influence religious affiliation has in social networks would be required to better explain these results.
6. Evaluating the role of number of families in respondents house Multiple regression models found that the number of families in the house was negatively correlated with ORS use, suggesting that social networks between maternal heads living in the same house do not play a role in encouraging ORS use. The number of families living in the same house as the respondents family was intended to be an indirect, inverse measure of affluence. Living in a one-family house vs. multi-family house was found to exhibit a substantive association with household expenditures and household income. The number of families in one house was also hypothesized to be a social network variable as well. Sharing the same house was speculated to facilitate transfer of ideas between mothers, since they would be spending more hours together and would live under similar circumstances. Many studies have showed positive correlation between strength of social networks and positive health outcomes (Ellison 1998, Langlie 1977), with only a handful showing otherwise (Benjamins 2005). The results of this study belong in the second category. Of note, within this study population, interpersonal networks within each of the communities do not seem to be vibrant, according to the data on friend networks and community involvement described previously. Having a strongly-woven community fabric or active social networks has been shown to be associated with greater likelihood of performing indirect preventive health
73 | P a g e behaviors in adults in the developed world, such as proper nutrition, exercise, and immunizations (Langlie 1977). In the population studied here, just over half of respondents surveyed lived in the same house as at least one other family. The vast majority of respondents felt like they were somewhat different or very different from the families living around them, and over half of respondents felt that they had zero or one close friend living in the same community. Over three-quarters of respondents attended fewer than two public or community meetings in a year. Given this information, it appears that most households operate independently and do not experience a strong connection with their neighbors or communities.
B. Limitations Several limitations should be considered in interpreting the findings of this study. Respondent bias due to knowledge that the project was about health, hygiene, and sanitation may have influenced responses regarding primary concerns, attitudes, and needs. Enumerators introduced themselves as working with authoritative organizations in the water, health, and sanitation field. Muhimbili University is a very well-known medical school in Dar, and DAWASA is the primary water and sanitation systems provider in Dar. Because enumerators also were required to state their affiliation with Stanford University per IRB, respondents may have believed that their responses would influence acquisition of material benefits from a United States university (even though respondents were informed that they would not be receiving any monetary or in-kind compensation). Respondents who were approached after the enumerators had spent several days in the same community may have even more information about the study,
74 | P a g e and it is uncertain how that information may have influenced a respondents willingness to participate in the study or the validity of her responses. Sample size could have been larger, if there had not been the physical limitation of having to take hand and stored water samples at each house. This put a limit on the number of houses each enumerator team could survey each day, because a large number of water samples would be too heavy to carry from house-to-house and back to the meeting point. This meant that fewer houses could be interviewed each day than in a survey-only study, and the research team spent a longer period of time in each community. A larger sample size would have yielded a more robust representation of the study population by increasing statistical power and decreasing the width of 95% confidence intervals. However, a sample size of 311 yielded fairly robust results. Unfortunately, model 2 describing sanitation had only 269 respondents, which may have prevented certain relationships from rising to statistical significance, but qualitative analyses on directionalities were observed. Random selection of the sampled houses could have been more systematic had the communities we worked in had more city planning. However, this would be a challenge for any household interview-based research project in Dar. The communities sampled were squatter settlements and largely unplanned, so they did not have an adequate network of roads or infrastructure. Ideally, houses would have been selected by some spatial pattern, such as counting off every two or three houses radiating out from water pumps (since water, health, and sanitation factors could be a function of distance from a water source). The method used was the most random and efficient possible.
75 | P a g e Language presents another challenge when researchers are not fluent in the local language. Although all reasonable precautions were taken against errors in translation, such as questions in which the literal meaning was translated, or the intent of questions did not carry over, still may have occurred. For example, in the question asking respondents about the causes of diarrhea, one of the choices in English is mosquitoes, reflecting an incorrect inference that malaria may cause diarrhea. In Kiswahili, however, the word mbu means insects of all sorts, and because flies hovering around open defecation and landing on food could cause diarrhea, the intent of the question and answer choice were lost in translation. Each of the surveys was reviewed with native Kiswahili speakers several times to ensure the greatest accuracy possible, so as great a level of confidence in the survey tool could be achieved. With regard to the content of the survey, one significant characteristic the survey tool neglected to include was how many wives the respondents husband had, what order wife she was, and the dynamics between her husband and his other wives. In both rural and urban regions of Tanzania, men frequently have two wives, and whether the respondent is the first or second wife would likely be associated with characteristics and beliefs. Another variable unaccounted for were the behaviors of the housegirl. Because of the demanding nature of maternal responsibilities, mothers commonly hired housegirls to help care for children and do work around the house. Housegirls were typically females in their teens who had completed primary school. In place of housegirls, older female siblings often served a similar role. Amongst our study population, forty-two (12.6%) respondents reported having an older child or house girl help take care of the children for more than half of the day. Although the behaviors of these housegirls would also influence child health outcomes, the overarching beliefs
76 | P a g e and behaviors of the maternal head of household would be expected to play a critical role in preventing childhood diarrhea.
B. Recommendations Morbidity and mortality caused by childhood diarrhea in Dar es Salaam has been recognized as a pressing issue by Tanzanian policy-makers and medical personnel in district hospitals, but current interventions have not brought numbers down to manageable levels. The challenges of adequate sanitation and hygiene have already been tackled from multiple angles, and results from this study offer recommendations for policy-makers, public health campaigns, and community leaders to increase the effectiveness of their work. In order to support the caregivers whose actions most-proximally influence childhood diarrhea, progress needs to be made by the public sector in providing affordable and dependable infrastructure for waste removal, increased support for female education, and renewed emphasis on urban planning to prevent overcrowding. Jointly, the public and private sectors should continue to expand opportunities for females in the workforce outside of the home, while being sensitive to the fact most women will concurrently hold responsibilities in the home. Public health campaigns and health educators should acknowledge that there is no straight answer to motivating behavior change. Findings suggest that any effective program will have to be attentive to the complexity surrounding the problems of hygiene, sanitation, water treatment, and ORS use. Since no factors explored in this study were found to be predictive of ORS use, no recommendations on how to increase its use at home fall out of this research. However, with regard to the other target behaviors, any educational efforts should take into
77 | P a g e consideration caregivers real-world ability to address the issues. The dissemination of knowledge about the risk factors is not enough to ensure performance of preventive behaviors; the effects of increased knowledge were found to be mediated by beliefs with relation to self- efficacy and empowerment in household decision-making. Civil sector organizations aiming to decrease childhood diarrhea and improve child health outcomes should explore development strategies that link income enhancement and maternal education with their project goals. Because each household is embedded within the context of its community or tencell, actions taken by community leaders and the social nroms around health, hygiene, and sanitation will influence maternal behaviors. Key figures in the community and well-established social networks should be utilized in the implementation of any intervention. Utilizing these traditional paths of trust and authority whether these paths include religious leaders, community leaders, family members, medical personnel, or the mediawould likely yield better outcomes, even if the topic at hand is unfamiliar for the target population. For example, men should be included in dialogue surrounding issues of child health, although this is typically in the maternal arena. In order for any project to be effective and have lasting impacts, community members should feel invested individually and collectively.
78 | P a g e
VII. CONCLUSION The results presented here describe the relationships between maternal beliefs and preventive behaviors known to reduce morbidity from childhood diarrhea as more complex than previously shown. While perceptions of self-efficacy were substantively associated with all of the behaviors, and empowerment was influential in reported water treatment, sociodemographic factors showed a high level of interaction with these behaviors. When all other variables were held constant, there were several key respondent characteristics that had significant explanatory power in predicting certain behaviors. Maternal education, age, and religion were important in reported hygiene and observed sanitation. Maternal employment and religion were correlated with reported water treatment. The model describing ORS use was not very powerful and of the variables examined, only number of families in the house was significantly associated.
79 | P a g e This study showed that each belief-behavior relationship was intricately linked to multiple other factors. Although self-efficacy showed the strongest trends across all outcomes in question, the degree of association varied from behavior to behavior. Maternal empowerment is now widely-accepted as improving child health outcomes, but the findings here suggest its effects are not as singularly predictive as previously concluded. Social and demographic factors mediate the effects self-efficacy, empowerment, and motivation have on the behaviors examined here. Lastly, knowledge of risk factors, promoted unilaterally by many health educators, was not important in reported or observed performance of any of the behavioral outcomes. This study expands the growing amount of literature supporting health behavior change theories to application in the developing world as well as the developed world where the efficacy of these theories have been examined. These theories tout beliefs such as self-efficacy and encourage educators to help individuals find mechanisms to overcome real-world constraints. In a changing global environment, these constraints are becoming increasingly prevalent and localized in resource-poor regions. The human population is proliferating at a skyrocketing pace, but the microbial world resists our conquest. Greater health and resource inequities put poorer populations at the front lines of health hazards and disproportionately suffer the greatest number of casualties. If more emphasis is not placed on preventive health, diseases such as those causing childhood diarrhea will continue to claim the lives of millions of victims each year. Further research on factors influencing health behaviors in the developing world will be critical to developing innovative solutions to these costly problems.
80 | P a g e APPENDIX A: DETAILED DISCUSSION OF CHOICE OF VARIABLES Sociodemographic characteristics For multivariate analyses, six characteristics were selected as covariates that may exert an influence on beliefs or behaviors: highest level of educational attainment, maternal employment, age of respondent, number of families living in the same house as the respondent, religion, and whether the respondent owned or rented the house she lived in. Education level was very closely correlated with ability to read and write (p<.001), and would reflect not only exposure to formal learning, but also to ideas and critical thinking. Maternal employment theoretically would be very closely associated with the measure for empowerment used in this study, especially given that the TDHS found maternal decision-making ability on household spending increased when mothers were employed. The mothers age serves as an indicator for lived experience, including personal experience with children and opportunities for informal education. The number of families in a household may influence perceptions of individual control over aspects of the respondents life; for example, having more families may deter the respondent from investing to improve sanitation if she felt the influence of those around her would eclipse individual efforts. Religious beliefs, values, and practices, especially those with regard to female roles, would be expected to exert influence on maternal beliefs and preventive behaviors. Ownership status of the house the respondent lives in may impact perceptions of stability and security; self-efficacy has been shown to increase with perceptions of more options and greater individual control over ones life, and house ownership would provide greater motivation to improve sanitation facilities if the respondent was certain she and her family would benefit from the investment in the long-run.
81 | P a g e A direct measure of household income and expenditures was omitted, because only 129 responses were provided for monthly household income. Including expenditures would have also necessitated the casewise deletion of 40 respondents who did not provide an answer to that survey question. Several other measures described above, such as house ownership, education level, maternal employment, families living in the same household, serve as an affluence proxy. The latter would be expected to have a negative correlation with affluence, while the others would likely be directly related. An ANOVA regression of independent variable inputs of work, religion, age, house ownership status, maternal education, and number of families in house yielded a highly significant relationship with weekly household expenses (p < .001, N=261) and with monthly household income (p < .001, N=105). Expenses and income, for the 105 respondents who answered both queries, were associated by a p-value of .001.
Knowledge Knowledge of diarrhea etiology may inform the beliefs/perceptions respondents may have over their ability to control whether their child gets diarrhea. Previous studies have examined the pathway of knowledge of etiology, focusing mostly on biomedical knowledge and understanding of germ theory (Andrzejewski 2005). In this study, I chose to look more at proximate factors that mothers may have control over or may be able to mitigate the effects of. Although the majority of individuals (87.4%) reported that they agreed with the statement that germs are the primary cause of illness, their responses to another question regarding what they believed childrens diarrhea could be caused by did not accurately reflect understanding or belief of germ theory. This discrepancy suggests that biomedical knowledge may be a less proximal factor in determining behavior outcomes. For example, even if mothers dont believe in germ
82 | P a g e theory but believe poor personal cleanliness can cause diarrhea, they may perform preventive behaviors that would increase hygiene, though perhaps not for the same Westernized reasons of preventing the spread of pathogens. It may be argued that maternal level of schooling may be predictive of knowledge level, but other variables such as informal education through lived experience may influence what mothers believe are causes of diarrhea. The knowledge variable was calculated as a score between 0-5 from a question prompting respondents to answer whether or not they thought a series of factors would cause diarrhea. Respondents were also asked if they thought factors other than the ones listed caused diarrhea. For the purposes of creating this variable, respondents were given one point for each response of yes to dirty/unsafe drinking water, eating rotten food, and poor personal cleanliness. Another point was assigned for every no answer to bad spirits or bad smells.
Self-efficacy, empowerment, and motivation A series of agree/disagree questions targeting knowledge, attitudes, and perceptions of the respondent were used to represent beliefs of self-efficacy, empowerment, and motivation. Because several of these questions closely reflected these beliefs, these questions provided valuable information that was used as the indicator variables for the three perceptions examined here. In modified versions of the health belief model and in the social cognitive theory model, self-efficacy exerts considerable influence over adopting health behaviors. Multiple studies have supported the importance of self-efficacy in behavior change (Jirojwong & MacLennan 2003; Kegler et al. 1999), and the most critical element is the belief that ones behavior can affect
83 | P a g e outcomes. Thus, the question asking the respondent whether she believes she can prevent her child from getting diarrheal illness is a robust assessment of the respondents perception of self- efficacy in this aspect of her childs health. Empowerment can be broadly defined as the power of choice, whether financially, methodologically, or definition of success (Kabeer 1999). In this study, the association between financial discretion and reported behaviors was examined, because past studies have shown that increased monetary decision-making power a caregiver exercises is positively associated with better child health outcomes or health behaviors (Koenen et al. 2006; Molyneux et al. 2002). Degree of motivation was inferred, given the sample populations reported trends in knowledge, attitudes, and perceptions, using reported level of satisfaction with the current sanitation situation. Since the large majority of individuals believed that germs caused illness and that surrounding families were dirty, it was surmised that individuals may be motivated to perform personal habits that would prevent their children from becoming ill.
84 | P a g e
Table 8. Distribution of sociodemographic characteristics, beliefs, knowledge, and behaviors Characteristic Freq. N=311 % Sociodemographic No formal education 31 10.0% Primary school 206 66.2% Secondary O 65 20.9% Secondary A 4 1.3% Vocational training 3 1.0% University 2 0.6% Maternal employment 58 18.6% Religion Christian 157 50.5% Muslim 154 49.5% Home ownership Own 180 57.9% Rent 131 42.1% Families in house (median, SD) 2, 2.6
Respondent age (median, SD) 28, 8.4
Belief/Perception High self-efficacy 227 73.0% High empowerment 255 82.0% High motivation 98 31.5% Knowledge score (mean, SD) 3.6, 0.8
Behavior/Outcome Hygiene (handwashes) 119 38.3% Sanitation (no visible feces)* 169 62.8% Water treatment (always) 165 53.1% ORS use 75 24.1% Under-5 child sick in last two days 71 22.9%
85 | P a g e APPENDIX B: SURVEY QUESTIONNAIRE Below is a subset of the 646 questions asked in first household survey. The questions regarding health and health information toward the end were administered during two other surveys of the same households.
Q.4 ***SELECT COMMUNITY YOU ARE WORKING IN: Mburahati, Sitakashari, Kitunda Q. 18 How many families live in your house on a regular basis? Q.19 HOW MANY PEOPLE live in this household on a regular basis? ***Household = family Q.40 Which of the following levels of education have you completed? .***TICK ALL THAT APPLY !. None 2. Primary 3. Secondary O 4. Secondary A 5. Vocational 6. University Q.63 In your view, what are the symptoms of diarrhea? ***Do not prompt. Tick all items mentioned. Watery stool 1 Defecating often 2 Vomiting 3 Blood in stool 4 Stomach pains 5 Fever 6 Other Dont Know Q.64 Specify other symptoms: ____________________________________________________________________ Q.65 Has any child in your household ever had a SERIOUS diarrheal illness? Q.67 In the next MONTH, how likely do you think it is that CHILDREN in your family will get diarrhea?. Q. 68 Do you think that childrens diarrhea could be caused by*** PROMPT on each answer and record response.
YES NO DON'T KNOW Insects/Mosquitoes 1 2 3 Changes in weather 1 2 3 Dirty/Unsafe Drinking Water 1 2 3 Eating Rotten Food 1 2 3 Bad Spirits? 1 2 3 Contact with Water Outside 1 2 3 Poor personal cleanliness 1 2 3 Bad smells 1 2 3 Malaria 1 2 3 Other Cause
Q.69 Describe other unprompted causes for diarrhea: _____________________________________________ Q.70 What do you do when your children have diarrhea? ***DO NOT PROMPT. Nothing, no treatment ...................................................... 1 Take to a clinic / doctor ................................................... 2 Give medicine at home* .................................................. 3 Give oral rehydration salts ............................................... 4 Visit traditional healer ..................................................... 5 Other (specify) ........................................................ 6 Don't know / No response ................................................ 7 Q.83 In the past 2 DAYS, have any of your family members been ill with STOMACH ILLNESS or RESPIRATORY INFECTION?
Q.84 Can you tell me WHICH family members have had stomach or respiratory infection in the past 2 DAYS? Q.85 What are [ANSWER TO Q. 15]'s SYMPTOMS, does s/he have... Q.86 Do you think these symptoms are serious?
86 | P a g e Q.148 Now Im going to read a series of statements. For each one, please tell me whether you DEFINITELY AGREE, AGREE SOMEWHAT, or DISAGREE.
Agree strongly Agree somewhat Disagree No response It is normal for children to get diarrhea regularly. 1 2 3 4 My family is clean compared to other families living near us. 1 2 3 4 Germs are the main cause of illness. 1 2 3 4 I can prevent my children from getting diarrheal illness.
1 2 3 4 We have enough water in our household for everyone to keep themselves clean. 1 2 3 4 I often make decisions about how to spend money on things for my family. 1 2 3 4 A mother who doesnt keep her children clean should be ashamed. 1 2 3 4
My familys health problems are caused by things I have no control over. 1 2 3 4 My family has more important priorities than improving our sanitation and hygiene situation.
1 2 3 4 I think many households in this area are dirty. 1 2 3 4 Only rich people wash their hands with soap. 1 2 3 4 Q.152 WHICH of the following WATER SOURCES does YOUR FAMILY USE on a regular basis? Private tap (own or neighbors) 1 Private well (own or neighbors) ........................................... 2 Public well ............................................................................ 3 A public tap .......................................................................... 4 Tankers/Cart Vendors .......................................................... 5 Bottled water ........................................................................ 6 Rivers, ponds, or canals ....................................................... 7 Rainwater collection ............................................................ 8 Any other sources? ............................................................... 9
Q.409 Do know of any ways to clean water that you use for drinking or cooking? Q.410 What are the methods you KNOW about for cleaning water? ***DO NOT PROMPT Boiling 1 Filtering with cloth 2 Ceramic/sand filter 3 Solar Disinfection 4 Chlorine 5 Other (specify) 6 Dont know 7
Q.412 Does YOUR FAMILY use any of these methods to CLEAN the water you use for DRINKING AND COOKING?
Q.413 Overall, HOW SATISFIED is YOUR FAMILY with your CURRENT water supply situation? Generally satisfied? ................................. 1 Somewhat dissatisfied? ............................ 2 Very dissatisfied? .................................... 3 Q.414 WHY is your family dissatisfied with your current water supply situation? ***DO NOT PROMPT. TICK ALL MENTIONED. Too EXPENSIVE (money) ........................................... 1
87 | P a g e Takes too much TIME to get water .............................. 2 NOT ENOUGH water for our needs ............................. 3 POOR QUALITY water / unsafe .................................. 4 Other (specify) .............................................................. 5 Q.426 Where do members of your family USUALLY go to the bathroom? Use the TOILET in our home ................................. 1 Inside home but NOT in a toilet .............................. 2 At a neighbor's toilet ............................................... 3 At a pay or public toilet .......................................... 4 Fields/Bushes .......................................................... 5 River/Sea/Pond ....................................................... 6 Other (specify) ........................................................ 7 Don't know / No response ....................................... 8 Q.434 How would your family RATE your toilet in terms of... ***Read out all categories Good Fair Poor Don't know ...Cleanliness? ...Functioning? ...Privacy? ...Convenience? Q.437 Has the pit/septic tank ever been emptied? Q.438 How was the latrine emptied? ***PROMPT if necessary. Tick all that apply. Vacuumed out by machine ................................ 1 Shovel/Bucket by hand ..................................... 2 Pit punctured on side during rains ..................... 3 Other (specify) .................................................. 4 Don't know / no response .................................. 5 Q.461 WHERE do the YOUNG CHILDREN in your family usually urinate and defecate? Potty ............................................................... 1 Diapers ........................................................... 2 Use the TOILET in our home ........................ 3 Inside home but NOT in a toilet .................... 4 At a neighbor's toilet ...................................... 5 At a pay or public toilet ................................. 6 "Wherever they can"/In the open ................... 7 Other (specify) ............................................... 8 Don't know/ No response ............................... 9 Q.462 ***Specify "other" place that children urinate and defecate: __________________________- Q.463 At about what age do children in your house start using a toilet? Q.475 Overall, HOW SATISFIED is your family with your CURRENT sanitation situation? Generally SATISFIED ...................................... 1 Somewhat DISSATISFIED .............................. 2 Very DISSATISFIED ....................................... 3 Don't know / No response ................................. 4 Q.476 WHY is your family DISSATISFIED? ***DO NOT PROMPT. Tick all that apply. Toilet pit/ tank is full .......................................... 1 Toilet clogs/breaks .............................................. 2 Bad smells 3 Not clean ........................................................... 4 Too far from home .............................................. 5 Too expensive ..................................................... 6 Not private .......................................................... 7 Embarrassing ........................................................ 8 Other (specify) ................................................... 10 Don't know / No response .................................. 11 Q.478 In general, how would you rate the sanitation practices of the households AROUND you? Q.481 Do you think your family will still be living in this house ONE MONTH from now? Q.482 Suppose your family had an EMERGENCY and NEEDED MONEY to cover your expenses for ONE WEEK. NOT including your family or close friends, are there OTHER families or organizations here in [ANSWER TO Q. 4] that would lend you this money? Q 483. What is your religion? (Christian, Muslim, Jewish, Atheist, Other)
88 | P a g e Q.484 There are often differences between people living in the same neighbourhood, such as differences in income, social status, and ethnic or linguistic background. There can also be differences in religious or political beliefs. Q.485 Thinking about ALL these types of differences, HOW SIMILAR is YOUR FAMILY to others in your community? ***PROMPT IF NECESSARY Very similar .............................................. 1 Somewhat similar ..................................... 2 Somewhat different ................................... 3 Very different ........................................... 4 Don't know/Could no respond Q.487 About how many CLOSE FRIENDS would you say you have in this community? Q.488 In a typical YEAR, about how many public or community MEETINGS does your family attend? Q.489 Finally, I'd like to ask a few more questions, about your FAMILY and your HOME. Q.490 Do you OWN or RENT your home? Q.504 How much do you think your family spends on REGULAR EXPENSES each WEEK? Q.505 About HOW MUCH does your family spend on HEALTH CARE each MONTH? Q.507 Does anyone in your household OWN a...
Q.513 Now I would like to ask if you have any help taking care of your children during the day. Does an older sibling or a house girl USUALLY help you feed or clean up after your children? No, no one helps me ............................................................ 1 Housegirl ............................................................................. 2 Older Sibling in the home ..................................................... 3 Another family member in this house ................................... 4 Someone else ....................................................................... 5 Don't know ........................................................................... 6 Q.527. Thinking about YESTERDAY, about how many times would you say that you WASHED your hands? Q.528 YESTERDAY, can you tell me WHEN you washed your hands? ***DO NOT PROMPT. Tick all mentioned by respondent. AFTER using the TOILET ........................... 1 AFTER cleaning up a child .......................... 2 BEFORE preparing food .............................. 3 AFTER preparing food ................................. 4 BEFORE eating ............................................ 5 AFTER eating .............................................. 6 BEFORE going out 7 Other ............................................................. 8 No response .................................................. 9 Q.530 What are the main REASONS that you WASH your HANDS? ***DO NOT PROMPT. Tick all mentioned by respondent. Remove DIRT/SOIL/FOOD ...................................... 1 Kill GERMS/ Be HEALTHY ..................................... 2 Appear CLEAN/ DECENT ........................................ 3 OBEY request of another person/mother .................... 4 Other .......................................................................... 5 No response ................................................................ 6 Q.634 May I please look at your toilet? Q.635 ***Enumerator: Please mark whether toilet has. YES NO ROOF? IMPROVED PIT/SEPTIC TANK? DOOR? A CONCRETE SLAB/FLOOR? YES, WORKING YES, NOT WORKING NO ...radio? 1 2 television? 1 2 ...refrigerator? 1 2 ...gas stove? 1 2 ...bicycle? 1 2 motorcycle? 1 2 car or truck? 1 2
89 | P a g e Q.636 ***Does the toilet have any visible feces around the pit/hole?? Q.637.***How much space is left in the pit or tank? Estimate in meters Q.1 Have any children in your family died before they reached the age of 5? Q.2 How many children in your family have died before the age of 5? Q.3 What was the cause of death for the first child who died before the age of five? Q.4 What was the cause of death for the second child who died before the age of five? Q.5 The last time your child had diarrhea, what did you do at home to try and help your child recover from his/her diarrhea? Nothing Gave homemade mixture of oral rehydration salts (rice water, coconut milk, watery soup) Gave child more fluids Gave child less fluids Gave child more food Gave child less food Child never had diarrhea Other Q.119 Families like yours can get information and advice about health from many sources. Can you tell me whether your family gets information about keeping healthy from the following sources OFTEN, SOMETIMES, or RARELY?
Often Sometimes Rarely Never Dont know Relatives Medical Professional (doctor, nurse)
NGO Staff Member Neighbor TV
Radio
Newspaper Health Clinics School events/school children
Traditional healers
90 | P a g e
REFERENCES Andrejewski CS. (2005). Knowledge of etiology in coastal Ghana: What do people know and how do they know it? Ph.D. Paper. Asnake M, Larson C, Teka DE. (1992). Water handling procedures and their association with childhood diarrhea. Ethiopian Journal of Health Development 6(2): 9-16. Bandura A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 84(2): 191-215. Benjamins MR. (2005). Social determinants of preventive service utilization: How religion influences the use of cholesterol screening in older adults. Research on Aging 27(4): 475-97. Bennett A. (2007). Young child survival and development: In a child survival milestone, under- five deaths fall below 10 million per year. UNICEF. Available at: http://www.unicef.org/childsurvival/index_40850.html. Accessed 6 June 2008. Bilenko N, Drora F, Lechaim N. (1999). Maternal knowledge and environmental factors associated with risk of diarrhea in Israeli Bedouin children. European Journal of Epidemiology 15(1): 907-12. Brigit O, Iteba N, Lengeler C, Makemba A, Mshana C, Nathan R, Alba S, Dillip A, Hetzel MW, Mayumana I, Schulze A, Mshinda H. (2007). Access to health care in contexts of livelihood insecurity: A framework for analysis and action. PLoS Medicine 4(10): 1584-88. Burian B and Alphonce KT. (2000). Sustainable development in an urban Tanzanian context. Naerus Workshop. UN Institute for Social Development. Ardhi Institute, Chaggu EJ, Mgana S, Rwegasira M, Mato R, Kassenga GK. (1993). Groundwater pollution, Majumbasita, Tanzania: Final report. Ardhi Institute, Center for Housing Studies, Dar es Salaam, Tanzania. Chaggu E, Mashauri D, Buuren JV, Sanders, Lettinga G. (2002). Excreta disposal in Dar es Salaam. Environmental Management 30(5): 609-20. City Mayors. (2006). The world's fastest growing cities and urban areas from 2006 and 2020. Available at: http://www.citymayors.com/statistics/urban_intro.html. Accessed 30 Dec, 2007.
91 | P a g e Cleland JG and Van Ginneken JK. (1988). Maternal education and child survival in developing countries: The search for pathways of influence. Social Science Medicine 27(12): 1357-68. Dale S. (2004). The integrated management of childhood illnesses tackles high rates of child mortality. Case Study: Fixing Health Systems. International Development Research Centre. Ottawa, Canada. Daniels DL, Cousens SN, Makoae LN, Feachem RG. (1990). A case-control study of the impact of improved sanitation on diarrhea morbidity in Lesotho. Bulletin of the World Health Organization 68(4): 455-63. Dearden KA, Quan LN, Do M, Marsh DR, Schroeder DG, Pachn H, Lang TT. What influences health behavior? Learning from caregivers of young children in Viet Nam. Food and Nutrition Bulletin 23(4); 117-27. Elder JP, Ayala GX, Harris S. (1999). Theories and intervention approaches to health-behavior change in primary care. American Journal of Preventive Medicine 17(4): 275-284. Ellison CG. (1998). The religion-health connection: Evidence, theory, and future directions. Health Education and Behavior 25(6): 700-20. Esrey SA, Potash JB, Roberts L, and Schiff C. (1991). Effects of improved water supply and sanitation on ascariasis, diarrhea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bulletin of the World Health Organization 65(5): 609-13. Greenberg H. (2005). Rotavirus vaccine and intussusceptions: A cautionary tale of risk assessment. Institute of Medicine of the National Academies. Available at: http://www.iom.edu/Object.File/Master/30/565/greenberg.pdf. Accessed 7 March 2009. Harpham T and Few R. (2002). The Dar es Salaam urban health project, Tanzania: A multi- dimension evaluation. Journal of Public Health Medicine, 24(2): 112-9. Hameed AM, Jalil A, Rozina N, Mughal I, Rauf S. (2002). Role of Islam in prevention of smoking. Journal of Ayub Medical College 14(1): 23-5. Heggenhougen KH, Hackethal V, Vivek P. (2003). The behavioural and social aspects of malaria and its control. Special Programme for Research and Training in Tropical Diseases, UNDP/World Bank/WHO. 3(1). International Food Policy Research Institute. (2002). Tanzania: Dar es Salaam urban livelihood challenges. Available at: http://www.ifpri.org/themes/mp14/profiles/daressalaam.pdf. Accessed 6 June 2008. Jirojwong S and MacLennan R. (2003). Health beliefs, perceived self-efficacy, and breast self- examination among Thai migrants in Brisbane. Journal of Advanced Nursing 41(3): 241-249.
92 | P a g e Kayombo EJ, Uiso FC, Mbwambo ZH, Mahunnah RL, Moshi MJ, Mgonda YH. (2007). Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. Journal of Ethnobiology and Ethnomedicine 3:6. Kabeer N. (1999). Resources, agency, achievements: Reflections on the measurement of womens empowerment. Development and Change 30: 435-64. Kassenga GR. (2007). The health-related microbiological quality of bottled drinking water sold in Dar es Salaam, Tanzania. Journal of Water and Health 5(1): 179-85. Kegler M, Malcoe LH, Kegler SR, Lynch RA, Tolliver R. (1999). Caregiver beliefs and behaviors in the prevention of childhood lead poisoning. Family & Community Health 22(1):50-65. Khan MM, Hotchkiss DR, Berrutland AA, Hutchinson P. (2006). Geographic aspects of poverty and health in Tanzania: does living in a poor area matter? Partners for Health Reformplus. Bethesda, Maryland. Kiwara AD. (2007). Group premiums on micro health insurance experiences from Tanzania. East African Journal of Public Health 4(1): 28-32. Koenen KC, Lincoln A, Appleton A. (2006). Womens status and child well-being: A state-level analysis. Social Science & Medicine 63:2999-3012. Kulwa K, Kinabo J, Modest B. (2006). Constraints on good child-care practices and nutritional status in urban Dar es Salaam, Tanzania. Food and Nutrition Bulletin 27(3): 236-44. Langlie JK. (1977). Social networks, health beliefs, and preventive health behavior. Journal of Health and Social Behavior 18(3): 244-60. Lorenz N and Mtasiwa D. (2004). Health in the urban environment: Experience from Dar es Salaam/Tanzania. Annals New York Academy of Sciences 1023: 159-63. Lugalla JLP. (1995). The impact of structural adjustment policies on womens and childrens health in Tanzania. Review of African Political Economy 22(63): 43-53. Luilo G and Kabudi P. (2003). Inadequacies in water legistaion for water resources management: Experiences from Tanzania. Journal of Water and Environment Technology 1: 1-6. McLennan JD. (2000). Prevention of diarrhea in a poor district of Santo Domingo, Dominican Republic: Practices, knowledge, and barriers. Journal of Health, Population, and Nutrition 18(1): 15-22. Majani B. (1996). Coping with urban growth and development through environmental planning and management (EPM): The sustainable Dar es Salaam project. Urban Health Newsletter 28: 26-31.
93 | P a g e Makule DE. (2000). Pollution of water sources due to poor waste management--the case of Dar es Salaam. Schriftenr Ver Wasser Boden Lufthyg 105: 117-21. Mamdani M and Bangser M. (2004). Poor peoples experiences of health services in Tanzania: A literature review. Reproductive Health Matters 12(24): 138-53. Matee MI, Msengi AE, Simon E, Lyamuya EF, Mwinula JH, Mbena EC, Mbena EC, Mbena EC, Samaranayake LP, Scheutz F. (1997). Nutritional status of under fives attending maternal and child health clinics in Dar es Salaam, Tanzania.. East African Medical Journal 74(6); 368- 71. Mayo AW. (2007). Prioritization of intervention methods for prevention of communicable diseases in Tanzania. Physics and Chemistry of the Earth 32: 1204-11. Mboera LEG, Rumisha SF, Senkoro KP, Mayala BK, Shayo EH, Kisinza WN. (2007). Knowledge and health information communication in Tanzania. East African Journal of Public Health 4(1): 33-39. Mbuligwe SE, Kaseva ME. (2005). Pollution and self-cleansing of an urban river in a developing country: A case study in Dar es Salaam, Tanzania. Environmental Management 36(2): 328-42. MKUKATA. 2005 National Strategy for Growth and Reduction of Poverty (MKUKUTA) Status Report. Molyneux CS, Murira G, Masha J, Snow RW. (2002). Intra-household relations and treatment decision-making for childhood illness: A Kenyan case study. Journal of Biosocial Science 34: 109-31. Montgomery CM, Mwengee W, Kongongo M, Pool R. (2006). To help them is to educate them: power and pedagogy in the prevention and treatment of malaria in Tanzania. Tropical Medicine and International Health 11(11):1661-69. Moorman C and Erika M. (1993). A model of consumers preventive health behaviors: The role of health motivation and health ability. The Journal of Consumer Research 20(2); 208-28. Moyo SJ, Gro N, Kirsti V, Matee MY, Kitundu J, Maselle SY, Langeland N, Myrmel H. (2007). Prevalence of enteropathogenic viruses and molecular characterization of group A rotavirus among children with diarrhea in Dar es Salaam Tanzania. BMC Public Health 7(1): 359. Mswia R, Whiting D, Kabadi G, Masanja H, Setel P. (2001). Dar es Salaam DSS Tanzania, adult morbidity and mortality project- phase 2. The International Development Research Centre. Available at: http://www.idrc.ca/en/ev-43009-201-1-DO_TOPIC.html. Accessed 10 October 2008.
94 | P a g e Mtango FD, Neuvians D, Broome CV, Hightower AW, Pio A. (1992). Risk factors for deaths in children under 5 years old in Bagamoyo district, Tanzania. Tropical Medical Parasitology 43(4): 229-33. Mukabana WR, Kannady K, Kiama GM, Ijumba JN, Mathenge EM, Kiche I, Nkwengulila G, Mboera L, Mtasiwa D, Yamagata Y, van Schayk I, Knols BG, Lindsay SW, Caldas de Castro M, Mshinda H, Tanner M, Fillinger U, Killeen GF. (2006). Ecologists can enable communities to implement malaria vector control in Africa. Malaria Journal 5: 9. Murcott S. (2006). Implementation, critical factors and challenges to scale-up of household drinking water treatment and safe storage systems. Background paper for electronic conference hosted by USAID/Hygiene Improvement Project. Available at: http://www.hip.watsan.net/page/1738. Accessed 11 October 2008. Murray C. (2007). Towards good practice for health statistics: Lessons from the Millenium Development Goal health indicators. The Lancet 369(9564): 862-73. Mwambete K and Kalison N. (2006). Prevalence of helminthic infections among underfives and knowledge on helminthiases among mothers of underfives in Dar es Salaam, Tanzania. East African Journal of Public Health 3(1): 8-11. National Bureau of Statistics (NBS), Tanzania, and ORC Macro. (2005). Tanzania demographic and health survey 200405, National Bureau of Statistics and Calverton. Dar es Salaam, Tanzania and MD, USA: ORC Macro. Available at: http://www.measureTDHS.com/pubs/pub_details.cfm?ID=566. Accessed 10 Sept 2008. PATH. (2009). Common virus and senseless killer: Briefing paper on Rotavirus. PATH. Washington, DC. Available at: http://www.path.org/files/IMM_rotavirus_briefing.pdf. Accessed 3 April 2009. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. (2003). Global illness and deaths caused by rotavirus disease in children. Emerging Infectious Diseases 9(5): 565-572. Schellenberg JA, Victora CG, Mushi A, de Savigny D, Schellenberg D, Mshinda H. (2003). Inequities among the very poor: Health care for children in rural southern Tanzania. The Lancet 361(9357): 561-566. Sethuraman K, Lansdown R, Sullivan K. (2006). Womens empowerment and domestic violence: The role of sociocultural determinants in maternal and child undernutrition in tribal and rural communities in South India. Food and Nutrition Bulletin 27(2): 128-43. Shayo NB, Chove BE, Gidamis AB, Ngoma OB. (2007). The quality of water in small community supplies of Kingolwira village, Morogoro, Tanzania. Tanzania Health Research Bulletin 9(1): 56-60.
95 | P a g e Sitakishari Water Committee Chair. Personal communication. Stanton BF, Clemens JD. (1987). An educational intervention for altering water sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhoea. American Journal of Epidemiology 125; 292-301. Sylvester B, Ivan RK. (2006). Association between poverty and malaria in randomly selected families in Dar es Salaam. Tropical Doctor 36(3): 184-5. Tanzania Census. 2002. Population and Housing Census General Report. Available at: http://www.tanzania.go.tz/census/census/districts. Accessed 10 Sept 2008. Tanzania Ministry of Health. (2003). Tanzania ministry of health. Available at: http://www.tanzania.go.tz/health.htm. Accessed 20 August 2008. Tolhurst R, Amekudzi YP, Nyonator FK, Squire SB, Theobald S. (2008). He will ask why the child gets sick so often: The gendered dynamics of intra-household bargaining over healthcare for children with fever in the Volta Region of Ghana. Social Science & Medicine 66: 1106-17. UNICEF. (2001). (E)quality: Girls and boys basic education in Masasi and Kisarewe Districts. Ministry of Education and Culture and Kuleana Centre for Childrens Rights. Research Report. Available at: http://www.unicef.org/evaldatabase/index_14610.html. Accessed on 10 Feb 2009. UNICEF. (2008). The state of the world's children 2007 executive summary. Available at: http://www.unicef.org/sowc07/docs/sowc07_execsummary.pdf. Accessed 10 Feb 2009. Villamor E, Misegades L, Fataki MR, Mbise RL, Fawzi WW. (2005). Child mortality in relation to HIV infection, nutritional status, and socio-economic background. International Journal of Epidemiology 34(1): 61-8. Walraven G. (1996). Willingness to pay for district hospital services in rural Tanzania. Health Policy and Planning 11(4): 428-37. White H. (2005). Maintaining momentum to 2015? An impact evaluation of interventions to improve maternal and child health and nutrition in Bangladesh. World Bank, Washington, D.C., p. 25. World Bank. (2003). Project appraisal document on a proposed credit in the amount of SDR 45.0 million to the United Republic of Tanzania for the Dar es Salaam Water Supply and Sanitation Project. World Bank document.
96 | P a g e World Bank. (2007). Tanzania Data Profile. Available at: http://devdata.worldbank.org/external/CPProfile.asp?CCODE=TZA&PTYPE=CP. Accessed on 10 June 2008. World Health Organization (WHO).(1993). The management and prevention of diarrhea: Practical guidelines, 3 rd ed. Geneva, Switzerland. WHO. (2007). Core health indicators. Available at: http://apps.who.int/whosis/database/core/core_select.cfm. Accessed on: 10 June 2008. WHO Committee on the Social Determinants of Health (CSDH). (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Convention on Social Determinants of Health. Geneva, Switzerland. WHO. (2008). World health Statistics. Available at: http://www.who.int/whosis/whostat/en/. Accessed on 10 Feb 2009. WHO. (2005). Multi-country study on womens health and domestic violence against women: Summary report of initial results on prevalence, health outcomes, and womens responses. World Health Organization. Geneva, Switzerland.
Fruits and Vegetables Consumption Pattern in School Children Ni Made Dewantari Dan Ari Widiani Abstract. Food Consumption in School Children Is Determined by Their Food