ASSESSMENT OF WATER, SANITATION AND HYGIENE IN PRIMARY

SCHOOLS OF KAWANGWARE SLUMS

BY

CHALI T. NEGASSA
MPH/113/01283

A RESEACH PROPOSAL SUBMITTED IN PARTIAL FULLFILLEMENT

FOR THE AWARD OF MASTER OF PUBLIC HEALTH IN
INTERNATIONAL HEALTH AND DEVELOPMENT
MOUNT KENYA UNIVERSITY
AUGUST 2014

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

Student Signature ,,,,. Date ..

Chali T. Negassa
MPH/113/01283

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

1.

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

2. SignatureDate..
Ms. Monicah Njoroge

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

TABLE OF CONTENTS
DECLARATION...........................................................................................................ii
ABSTRACT.................................................................................................................iii
TABLE OF CONTENTS..............................................................................................iv
ABBREVIATIONS/ ACRONYMS...............................................................................v
OPERATIONAL TERMS.............................................................................................vi
CHAPTER ONE: INTRODUCTION............................................................................1
1.1
Background to the study.....................................................................................1
1.2
Statement of the problem....................................................................................4
1.3
Purpose of the study............................................................................................5
1.4
Objectives of the Study.......................................................................................5
1.5
Research questions..............................................................................................6
1.6
Hypothesis.........................................................Error! Bookmark not defined.
1.7
Justification and Significance of the Study........................................................6
1.7.1 Justification.........................................................................................................6
1.7.2 Significance........................................................................................................8
1.8
Delimitation and limitation of the study.............................................................9
1.8.1 Delimitation........................................................................................................9
1.8.2 Limitation.........................................................................................................10
1.9
Theoretical framework......................................................................................10
1.10 Conceptual framework......................................................................................10
CHAPTER TWO: LITERATURE REVIEW..............................................................12
2.1Availability and utilization of water.......................................................................12
2.2 Availability of adequacy sanitary facilities............................................................13
2.3 Hygiene practices among the primary school children..........................................15
CHAPTER THREE: RESEARCH METHODOLOGY..............................................16
3.1
Research Design................................................................................................16
3.3
Target population..............................................................................................16
3.4
Sampling techniques and sample size.................................................................17
3.4.1 Sample size....................................................................................................17
3.4.2 Sampling techniques.....................................................................................18
3.5 Construction of research instruments.......................................................................19
3.6 Pre-testing /Pilot Study..........................................................................................19
3.7 Recruitment and Training of Research Assistants.................................................19
3.8 Data collection methods and procedures...............................................................20
3.9 Logistical and Ethical Considerations...................................................................21
3.10 Data analysis techniques and procedures............................................................22
REFERENCES............................................................................................................23
APPENDIX 1: SCHOOL QUESTIONNAIRE FORM...............................................28
APPENDIX 2: PUPILS INTERVIEW QUESTIONNAIRE......................................31
APPENDIX 3: MAP OF KAWANGWARE WARD...................................................36
APPENDIX 4: TIME FRAME....................................Error! Bookmark not defined.
APPENDIX 5: BUDGET.............................................Error! Bookmark not defined.

ABBREVIATIONS/ ACRONYMS
MDG

Millennium Development Goals

KNBS

Kenya National Bureau of Statistics

UNICEF

United Childrens Education Fund

WHO

World Health Organization

SWASH

School, Water, Sanitation and Hygiene

SPSS

Statistical Package for Social Solutions

KNBS

Kenya National Bureau of Statistics

NESHP

National Environment and Sanitation and Hygiene Policy

WASH

Water, sanitation and hygiene

APHRC

Africa Population and Health Research Center

MoE

Ministry of Education

MoPHS

Ministry of Public Health and Sanitation

UN

United Nations

OPERATIONAL TERMS
Diarrhoea: is defined as the passage of three or more loose or liquid stools per day
(or more frequent passage than is normal for the individual).
Sanitation refers to means of preventing human contact from the hazards of waste to
promote health and includes the provision of facilities and services for the safe
disposal of human feaces and urine, but it can also be used to refer to the maintenance
of hygienic conditions, through services such as garbage collection, including for
menstrual hygiene protection materials, and wastewater disposal.
Health promotion refers to the process of enabling people to increase control over
the determinants of health and thereby improve their health.
Hygiene is the method of using cleanliness as a method of preventing disease.
Hygiene education refers to the provision of education and / or information to
encourage people to maintain good hygiene and prevent hygiene related diseases.
Hygiene facilities for schools refer to hand and body washing amenities, and sanitary
bins in girls toilets and dustbins.
Hygiene promotion refers to the planned, systematic attempt to enable people to take
action to prevent or mitigate water, sanitation and hygiene related diseases.
Intervention - the act or fact or a method of interfering with the outcome or course
especially of a condition or process as to prevent harm or improve functioning
Personal hygiene refers to keeping the body clean to prevent disease.
WASH facilities includes water supply facilities, latrines, hand-washing facilities,
incinerators, refuse pits, and other waste collection and disposal facilities
Water sources refers to spring water, tap water, shallow wells, rain water harvesting
6

CHAPTER ONE: INTRODUCTION

1.1 Background to the study
Water is a basic necessity of life. All living things man, animal and plants all depend
on water for their life to continue. However, for millions of children, the water they
drink can also be a source of persistent illness, leading to an early death. Globally, a
child dies of diarrheal disease every 40 seconds WHO (2013). The share of this big
number of deaths due to diarrhea is concentrated in Sub Saharan Africa where 1 in 8
children dies before reaching the age of 5 is about 17 times the average of developed
countries where under five death rates is recorded to be 1 in 143 children UNICEF
(2011). The same assessment data from 51 least developed countries and other lowincome countries recorded that an average of 49% schools do not have access to safe
water, and 55% schools do not have access to adequate sanitation facilities

Diarrheal diseases cause an estimated 801,000 deaths per year, mostly among
children under 5 years of age in developing world (Liu L, et al., 2010). A major
contributing factor to this burden of disease is inadequate access to safe water
and sanitation facilities. Access to safe drinking water and adequate sanitation
services is vital to human health and is one of the most efficient ways of improving
human health as shown by robust evidence of the impact of improvements in access
to water; sanitation and hygiene (WASH) at home on the health of children under 5
years (Curtis & Cairncross 2003; Clasen et al. 2007& 2010).
However gaining access to improved WASH is not simple as many people might
think. It takes several years and billions of dollars to realize (Blanton E. et al., 2010).
1

Currently over 780 million people in the world lack access to water supply, and
approximately 2.5 billion lack access to sanitation facilities (WHO and UNICEF,
2012). SWASH envisages a world where all children attend school regularly and all
schools provides safe, healthy and conducive environment where children develop,
gain knowledge and thrive. It aims to ensure schools have access to adequate child
friendly, gender and disability sensitive water and sanitation structures including
hand washing facilities and hygiene education programme (www.unicef.org).

The Kenyan National School Health Policy goal and objectives as stated by GOK,
(2009) is to enhance the quality of health in school communities by creating a
healthy and child friendly environment for teaching and learning and its objectives
include: Promotion of disease prevention and control as well as promotion of
hygiene, sanitation and use of safe drinking water.
The Kenya National Environment and Sanitation Policy (NESP) envisages that by
2015, every school will have hygienic toilets and hand washing facilities separate for
boys and girls and attainment of this goal is expected to reduce the incidence of
sanitation related diseases. The Policy further reveals that 80% of the hospital beds
in Kenya are occupied by patients suffering from preventable diseases. About 50%
of these illnesses are water, sanitation and hygiene related (MOH, 2007).
The source of drinking water is an indicator of whether it is suitable for drinking.
Sources that are likely to provide water suitable for drinking include a piped source
within the dwelling or plot, public tap, tube well or borehole, protected well or
spring, and rainwater. According to the recent Kenyan Demographic and Health

survey only 63 percent Kenyans get drinking water from improved source with clear
inequality between urban and rural residents. Urban households approximated to 91
percent have access to improved drinking water sources as compared to 54 percent
of their rural counterparts (KDHS, 2008/9). The Kenya demographic Health Survey
(KDHS) 2008/9, did not capture data on Schools and hence a gap to be addressed by
this study.
Ensuring adequate sanitation facilities is a Millennium Development Goal (MDG)
that Kenya shares with other countries. According to KDHS of 2008/9 a population
accounting 30 percent urban and 20 percent rural residents have access to improved
toilet facilities that is not shared with other households. In rural Kenya 47 percent
households use the most common open pit latrine without a slab, while 52 percent of
urban households shares toilet with other households. Overall, 12 percent of
households have no toilet facility at all; they are almost exclusively rural, accounting
for 16 percent of rural households (KDHS, 2008/9). The Kenya demographic Health
Survey (KDHS) did not capture data on Schools water and sanitation, and hence a
gap to be addressed by this study.
The study area is Kawangware slums of Dagoretti Sub County in Nairobi County. It
has hundreds of thousands of residents, many of whom are children. Water supplied
by the city authority is not available every day and safe drinking water is expensive
in Kawangware and most people there live on less than $1 USD a day
(www.leeonenessfoundation.com).
Kawangware slum is characterized with scarcity of safe drinking water, water borne
diseases, respiratory pneumonia, malaria as well as an increase in cases of airborne

diseases due to the poor drainage system. Safe drinking water is expensive to get.
The cost of living in Kawangware is one of the highest in the world after Kibera and
Mathare respectively (www.africalightchristian.org).

1.2 Statement of the problem

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

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

The specific objectives are:

1.4.1

To assess the availability of adequate water for both drinking and hygiene in

1.4.2

primary schools in Kawangware slums

To assess the availability of adequate sanitary facilities separate for boys and

1.4.3

girls in Kwangware primary schools.

To assess the hygiene practices among the primary school children in
Kawangware slums.

1.5 Research questions

1.5.1

What is the level of public primary schools in Kawangware slums access to

1.5.2

safe drinking water?

What is the extent at which Public Primary schools in Kawangware slums

1.5.3

have adequate sanitary facilities?

Do the Pupils in Primary Schools in Kawangware wash hands with soap at
critical times?

1.6 Justification and Significance of the Study

1.6.1

Justification

The success of any health policy or health care intervention depends upon a correct
understanding of socio-economic, environmental and cultural factors which determine
the occurrence of diseases and deaths.

In SWASH interventions, the success is

determined by how good the school environment ensure social, cultural and emotional
wellbeing of the young ones through providing basic water supply, sanitation facilities
and proper hygiene awareness in order to enable and promote a healthy child friendly
school.
The Baseline Survey done by Ministry of Education (MOE) in 2010 revealed that, 37.3
percent primary schools had safe drinking water sources in their compound or within
6

200 meters from the school yard, 86.9 percent schools had child friendly separate
latrines for girls, boys and school personnel although, less than a quarter (less than 25%)
of them complied with the countries standard (UN, 2012) . This non compliance to the
standard indicates that the facilities may be available in some of the schools but falls
short of the standard when the numbers of facilities are checked against student ratio.

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

The recent studies carried out in three primary schools in Kibera Slums, had appeared to
be highly varying regarding student toilet ratio. In this study the average ratio of toilet
for both boys and girls are 1:25, 1:33, and 1:103 for Premier Acadamy, Toi Primary, and
Boon House Primary schools respectively. Concerning hand washing , Bon house school
scored the highest with 75% of total children observed washing hands with soap, where
as Premier Academy and Toi Primary recorded 65% and 38% respectilely (Rufus

Eshuchi, 2013). However, the soaps used in these schools were provided by the
researcher for the study purpose.
The different studies carried out in Kenya Primary schools, mostly were done on WASH
impact, Menstrual hygiene management (MHM), Hand washing practices, Retention of
hygiene education owing big variation in their results indicating shortage of reliable data
regarding the current status of national SWASH interventions in Kenya
(Washmapping.com & Alexander, K.T. et al., 2014.).
Therefore, this study aspires to fill the gaps in knowledge by conducting an assessment
of water, sanitation and hygiene (WASH) interventions in schools in Kawangware slums
thereby establishing the level of achievements in regard to the international and local
plans and strategies. The assessment will also help to come up with documented
evidence regarding the level of access to SWASH facilities and proper utilization of
SWASH services. This will help to make available the necessary information and
documented evidence for Kwangware and other similar slum in the country.
1.6.2

Significance

The assessment of SWASH is important in the sense that water is important for the
welfare of the children, sanitation is for the prevention of the diseases and good hygiene
to create awareness through provision of health related information. This study is critical
for Kawangware primary schools as it is situated in a poor and marginalized area where
similar studies have not been conducted.
The results of the study will be used by both primary stakeholders such as MOE, MOH,
and secondary stakeholders such as national and international NGOs, civil societies, and

international organizations. The findings will in particular benefit Stakeholders in

Education sector and the pupils in Kawangware slums.
1.7 Limitation and Delimitation of the study
1.7.1 Limitations of the study
Studies have various limitations of their own (Leedy & Ormrod, 2005), or they have
potential weaknesses or problems with the study identified by the researcher (Creswell,
2005:198).

This study will be conducted in public government schools situated in Kawangware

slums where basic public services are believed to be scarce. Hence, the result will be
limited to slums of similar nature and will not possibly represent the other WASH
resource and facilities scarce communities in the urban or rural areas of the Republic of
Kenya. The study will also be limited to, Government of Kenya Public Primary Schools
partly due to time and financial constraints and will not sample public private/ mission
schools and hence the result will be indicative of the current coverage status of public
primary schools and may not truly represent others. Moreover, the respondent to the study
may be possibly mentored by the school teachers to answer the questionnaires in a certain
ways that may jeopardizes the result and hence the study result might not, therefore, be truly
representative of the schools.

1.7.2

Delimitations of the study

Delimitations is what the researcher is not going to do (Leedy & Ormrod, 2005).

This study will be conducted in all randomly selected Public Primary Schools in
Kawangware slums. It is delimited to only those Public Primary Schools in Kawangware
9

slums and not other areas. Generalization to other areas other than from public primary
schools in similarly known slums such as Kibira, Mathare, Korogocho.. may not be
warranted.

Kawangware is selected as the study site for the area is known to the researcher and it is
also a slum area where basic services are believed to be scarce. The study will cover
three key areas of the WASH: access to Water, Sanitation and Hygiene Promotion. In the
area of knowledge attitude and practice on hygiene, the study will purposefully
interview systematically selected pupils using the class register from standard 3 and 4 of
sampled primary schools. The results of this study will be limited for generalization
except for areas like Mathare, Kibera, korgocho.. that are similarly classified as slums.
1.8 Theoretical framework
The overall objective of UNICEF and other Partners in the area of water, sanitation and
hygiene (WASH) is to contribute to the realization of childrens rights to survival and
development through promotion of the sector and support to national programmers that
increase access to, and use of, safe water and basic sanitation services, and promote
improved hygiene in an equitable and sustainable manner. The sustainability of WASH
programs has three pillars for enhanced child survival and development. These are
Availability of WASH services, Enabling environment and behavioral change.
1.9 Conceptual framework
Addressing a childs right to health and education through the provision of WASH
ensures that all children have access to high quality water and sanitation services at
school, and the benefit of hygiene education. School-based WASH activities
represent an opportunity to directly address a childs right to both education and
health since access to safe drinking water and adequate sanitation services is vital to
human health and has benefits as shown in conceptual framework in figure 1, if all
schools provide WASH interventions.
10

INDEPENDENT VARIABLE

ENABLING VARIABLE

Availability of adequate
and improved water
supply throughout school
calendar.
Availability of adequate,
improved sanitation
facilities separate for boys
and girls.

DEPENDENT VARIABLE

Behavioral change

Proper, equitable use and

management of facilities,
good personal and
environmental Hygiene
Practice

Availability of sufficient
SWASH awareness
education and materials.

Figure 1: Researchers conceptual framework

11

Improved health

Healthy and
child friendly
school with
reduced
absenteeism

CHAPTER TWO: LITERATURE REVIEW

2.1Availability and utilization of water

Globally statistics show that school water coverage has increased from 63 percent in
2008 to 70 percent in 2010 (UNICEF, 2010a). The WASH intervention in school has
been documented to have positive evidence of the health of the pupils, including
psychosocial and educational benefits. For example, evidence shows that school-based
WASH programs reduce absence and parasitic infection (Bowen, Ma et al., 2007;
Freeman, Clasen et al., 2011; Freeman, Greene et al., 2011).
In low income countries data on access to water and sanitation in schools is scarce. An
evaluation by UNICEF found that in schools in 49 low-income countries, only 51% had
access to adequate water and 45% had adequate sanitation facilities (UNICEF, 2012).
WASH in Africa has made different levels of progress towards the Millennium
Development Goal. Northern Africa and Sub-Saharan Africa recorded completely
different levels of achievements. North Africa has 92% coverage and is on track to meet
its 94% target before 2015. However, Sub-Saharan Africa is in general off track at 61%
water coverage and with the current pace cannot meet the 75% target for the region (UN
2012).
An analysis of data from 35 countries in sub-Saharan Africa (representing 84% of the
regions population) shows significant differences between the poorest and richest fifths
of the population in both rural and urban areas. Over 90% of the richest quintile in urban
areas use improved water sources, and over 60% have piped water on the premises. In
12

rural areas, piped-in water is non-existent in the poorest 40% of households, and less
than half of the population use any form of improved source of water (UN 2012).
Kenyas national environmental sanitation and hygiene policy (NESHP) in its goal
number ii indicated that by 2015, every school, institution, household, market and
other public place will have access to, and make use of hygienic, affordable, functional,
and sustainable toilet and washing facilities (NESHP, 2007).

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

13

as compared to number of pupil. Shortage of water supply facilities and classrooms for
the ever increasing number of pupil are significant issues particularly in populated
schools. Moreover, the study also indicated maintenances of facilities as another key
issue that needs to be given attention together with capacity building (UNICEF 2009)
Ensuring adequate sanitation facilities is a Millennium Development Goal that Kenya
shares with other countries. According to the KNBS of 2008/9 less than one-quarter of
households use an improved toilet facility that is not shared with other households.
Urban households are only slightly more likely than rural households to have an
improved toilet facility (30 percent and 20 percent, respectively). The most common
type of toilet facility in rural areas is an open pit latrine or one without a slab (47 percent
of rural households), while in urban areas toilet facilities are mainly shared with other
households (52 percent). Overall, 12 percent of households have no toilet facility at all;
they are almost exclusively rural, accounting for 16 percent of rural households (KNBS,
2008/9).
In a study on the impact of WASH interventions in Nyanza, there was a 58% reduction
in the odds of absence for girls concluding that the improvement in the availability of
SWASH can improve school attendance for girls (Matthew C. Freeman et al., 2011).
In a Baseline Survey done in 2010 in 22 districts supported by Unicef SWASH
programme in 343 sampled schools, found out that, about 63% of schools did not have
safe water sources in their compounds. Though most of the schools had separate, gender
specific latrines, only 20% meet the ratio of national pupil to toilet ratio standards for
boys or girls (Baseline Survey 2010).
Safe excreta disposal by using improved latrines can reduce the risk of diarrheal by 32%
14

(Fewtrell, 2005). Moreover, SWASH intervention is found to promote girls attendance

and reduces absentiseem by 39% particularly when the school toilet ensures privacy,
cleanliness, and safety at the time of menstruation (UNICEF, 2010).

2.3 Hygiene practices among the primary school children

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

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

15

CHAPTER THREE: RESEARCH METHODOLOGY

3.1

Research Design

This is a descriptive cross-sectional study. Quantitative and qualitative methods will be

used to collect data in order to achieve the aim of the study. Semi structured
questionnaire and key informant interviews will be administered to the pupils and head
teachers respectively.

3.2 Location of the study

Kawangware division is one of the two divisions in the sub county of Dagoretti under
Nairobi county in Kenya. It is located about 15 kilometers west of the city centre of
Nairobi. It is Kenyas second largest slum after Kibera, and the fourth largest in Africa
with a population of over 300,000 people. It is one of the fastest growing and poorest
slums in the city (KNBS., 2009).
3.3

Target population

The target populations for this study will be sampled schools from Kenya public Primary
Schools in the division of Kawangware slums in Dagoretti Sub County. 10 pupils from
each class 3 and 4 will be systematically selected as shown in sampling frame or
techniques. The head teacher or health teacher will be the key informants from each
school and hence will be responding to various questions regarding major WASH
facilities in their respective school. The questions include some vital demographic
questions, availability and status of the facilities verses utilities as well as mechanisms

16

of managing the facilities that will be verified together with the investigator through
observation as indicated in Appendix I: school questionnaire form.
3.4

Sampling techniques and sample size

3.4.1 Sample size

Since there was no clear information on the coverage of Schools by SWASH programs
and available information are contradicting and great variability has been observed, the
study will use 50% proportion as the coverage of the SWASH intervention (Fisher et al,
1983). The Dagoretti sub county has two divisions, namely Kwangware and Waithaka
divisions. According to KNBS 2009 census, the total population of the Dagoretti sub
county is 329,577 and the total number of primary school age children 6-14 years are
53,890. Data obtained from Dagoretti sub county education office reveals that 20,851
pupils have been enrolled in the 24 public primary schools in the sub county whereas
other significant number of students go the various formal and informal private schools.
The population of primary school potential age group (6-14 years) in Kawangware
division is assumed to be at least about half the 53,890 in the two divisions of the
Dagoretti sub county. This still produces a sampling population of approximately
27,000potential age group. However, the actual student enrollments at the beginning of
2014 is 20,851. If we assume that the pupils enrolled in Kwangware division is about
half, the sample population can be approximated to 10,500 which is still over 10,000
children. The desired sample size is therefore obtained by applying Fishers formula for
sample size determination as follows:
n 2 1-

2
(1-p)

____________
2
d

Where;

n = sample size
1- (standard normal deviation at 95% confidence level) = 1.96
d (Absolute precision) = 5%
p (SWASH coverage) = 50%
n = (1.96)2 (0.5) (1- 0.5)
(0.05)2
2
n = (1.96) (1- 0.5)2 = 384
(0.05)2
17

Therefore number of respondents will be 384.

For smaller sample such as school in this case, to arrive at the sample size of the schools
to be assessed out of the 24 school available in Kawangware Division:
nf = n/(1+n/N)
nf = n/ (1+n/N) = 385/ (1+384/24) =21

schools.

Where: nf = desired sample size when target population is less than 10,000
n= sample size when target population is greater than 10,000
N = an estimate of the target population (24 primary schools)
However, to harmonize the Kenyan comprehensive school health implementation
handbook and the fishers formula of sample size determination, the researcher would
like to do the studies in 20 primary schools where in each school 20 students will be
interviewed from standard 3 and 4.
3.4.2 Sampling techniques
All 24 Public primary schools will be listed and given numbers that will be prepared in a
form of raffle as follows: 24 small pieces equal size paper will each have a number
constituting each of the school ( i.e. 1 to 24) rolled and put into deep container and
properly mixed and 20 schools will be randomly be picked for the assessment or the four
schools to be excluded will be picked from the 24 raffles prepared representing each
school, whichever method is easier. The Key Informant to be interviewed will be the
Head Teachers (or the Health Teacher) of the respective sampled primary schools. The
pupils to be interviewed from the sampled primary schools will be those from class 3
and 4 using the GOK Kenya Comprehensive School Health Implementation Handbook
(CSHIH). The Handbook recommends interviewing 20 children 10 children from each
class 3 and 4, through random sampling using registers eg every 5th child.

18

3.5 Construction of research instruments

Data collection tools will be constructed to collect both quantitative and qualitative data.
Key informant interview schedule Appendix II (School Form Interview), will be
constructed to collect information from the head teacher or health teacher on
demographic data, number and status of available WASH facilities, management of the
facilities, availability of utilities. The questionnaires are filled (completed) by the
through observation and response obtained from the respondents. Information will also
be collected from the students using Appendix III (Pupils interview questionnaire form)
that deals with the type of WASH facilities they have at home and detailed questions
related to the knowledge, attitude and practice of hygiene/health education.
Questionnaires in Appendix II are divided into parts which are variables. Part I,II,III,IV
and V. This parts are variables namely: I) Demographic Information, II) Availability and
Access to safe drinking water, III) availability and access to sanitation facilities, IV)
Provision and access to hand washing facilities and V) provision of hygiene education.

3.6 Pre-testing /Pilot study

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

3.7 Recruitment and Training of Research Assistants

A total of 4 research assistants will be recruited to collect data (2 males and 2 females)
for gender balancing. They should have completed secondary education and this will
help in understanding the context of the proposed study. The research assistants will be
19

given adequate training on data collection, interview techniques and ethical issues
needed in data collection. To ensure standardized performance and achieve the required
reliability of the study, the interviewers will be paired off to practice out interviewing
among themselves till the required objectivity is reached.

3.8 Data collection methods and procedures

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

20

3.9 Logistical and Ethical Considerations

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

In Kenya, it's customary that teachers sign health club activities, projects and field trips
consent forms on behalf of parent/guardians. Kenyan Parents regard and assign the
school a high level of guardianship and confident on the capacity of teachers to assess
21

the benefits of pupils participation in selected school activities. This is mainly because
of the adult literacy level that is believed to have an effect on the understanding of most
parents. According to the 2000 UNISCO assessment of education and average years of
schooling of adults, Kenya recorded an average of 4.2 years of formal schooling in
contrast of the lower 0.8 and the highest 12 years of schooling recorded in GuineaBissau

and

the

USA

respectively

(http://www.nationmaster.com/country-

info/stats/Education/Average-years-of-schooling-of-adults). It is due to this limitation in

education level, schools normally use the responsibilities delegated to the teachers by
parents/guardians committee to evaluate the right and benefit of their minor children and
consent on their behalf. As a result, schools do not have a custom of sending
parents/guardians to sign for consent to undertake certain activities. Therefore, for this
particular study, the researcher believed it was most appropriate to follow the same trend
that the pupil and their teachers/principals sign the consent form rather than the
parents/guardian.
3.10 Data analysis techniques and procedures
Data obtained from all forms of interview and checklist will be checked at the end of
each day by the researcher to ensure they are correctly completed. Data will then be
cleaned, coded and entered into the computer for analysis using SPSS version 20.0.
Descriptive statistics will be adopted using measures of central tendency at 95%
confidence level. Data will be presented using frequency table and percentages. Analysis
of contingency tables will be done and chi square statistic will be used to test for
association between variables and level of significance.

22

3.11 REFERENCES
Alexander, K.T.; Oduor, C.; Nuthatch, E.; Laserson, K.F.; Amek, N.; Eleveld, A.; Mason,
L.; Rheingans, R.; Beynon, C.; Mohammed, A.; Ombok, M.; Obor, D.; Odhiambo, F.;
Quirk, R.; Phillips-Howard, P.A. Water, Sanitation and Hygiene Conditions in Kenyan
Rural Schools: Are Schools Meeting the Needs of Menstruating Girls? Water 2014, 6,
1453-1466)
APHRC (2008) African Population and Health Research Working Paper 42, 2008:
Determining Appropriate Entry Point for Health Promoting Schools Intervention in
Nairobis Informal Settlements. Osnat Keidar, Elliot M. Berry, Alex C. Ezeh, Milka
Donchin. Available at: http://urbanhealthupdates.wordpress.com/2009/07/09/kenyasurvey-of-school-hygiene-in-nairobis-informal-settlements/,, accessed Oct 2014.
Baseline

(Survey

2010).

www.washinschoolsmapping.com/projects/Kenya.html).

Retrieved on 02/07/2014.
Blanton, E., Ombeki S., Oluoch G. O., Mwaki A., Wannemuehler K., Quick R. (2010).
Evaluation of the role of school children in the promotion of point-of-use water
treatment and handwashing in schools and householdsNyanza Province, Western
Kenya, 2007. American Journal of Tropical Medicine and Hygiene 82 (4): 664-71.
Bowen A., Ma, H., Ou, J., Billhimer, W. Long, T. Et al. (2007). A cluster-randomized
controlled trial evaluating the effect of a handwashing-promotion program in Chinese
primary schools. American Journal of Tropical Medicine and Hygiene 76 (6): 11661173.
Clasen TF, Bostoen K, Schmidt WP et al. (2010) Interventions to improve the disposal
of human excreta for preventing diarrhea. The Cochrane database of systematic reviews
6, CD007180.
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Creswell, J., 2005. Educational research: Planning, conducting, and evaluating quantitative
and qualitative research (2nd Ed.). Upper Saddle River, NJ: Pearson.

Curtis V & Cairncross S (2003) Effect of washing hands with soap on diarrhea risk in
the community: a systematic review. The Lancet Infectious Diseases 3, 275281.
Elizabeth Blanton, Ombeki S, Oluoch G, Mwaki A, Wannemuehler K & Quick R (2010)
Evaluation of the role of school children in the promotion of point-of-use water
treatment and handwashing in schools and householdsNyanza Province, Western
Kenya, 2007. American Journal of Tropical Medicine and Hygiene 82,664671.
Fisher, R. A. 1983. Statistical Methods for Research Workers. 30 th edition. Hafner
Publishing Company. New York. USA.
Freeman, M., Clasen T., Brooker S., Akoko D., Brumback B., Rheingans R. Et al.
(2011). The impact of a school based hygiene, water treatment, and sanitation
intervention on re-infection with soil transmitted helminths in western Kenya: a clusterrandomized trial. Paper presented at the Water and Health Conference: Where Science
Meets Policy. Chapel Hill, NC.
Freeman, M., Greene, L., Driebalbis R., Saboori S., Muga R. et al. (2011). Assessing the
impact of a school-based water treatment, hygiene, and sanitation program on pupil
absence in Nyanza Province, Kenya: A cluster randomized trial. Tropical Medicine and
International Health. DOI: 10.1111/j. 1365-3156.2011.02927. x. [E-pub ahead of print].
Government of Kenya (2009) National School Health policy Ministry of Public Health
and Sanitation and Ministry of Education
Government of Kenya (GOK). Kenya Comprehensive School Health Implementation
Handbook. Page 23-24.
24

http://webcache.googleusercontent.com/search?
q=cache:x593bBFn0kMJ:www.unicef.org/kenya/wes.html+&cd=1&hl=en&ct=clnk.
Accessed on August 2014.
http://www.unicef.org/wash/index_43084.html. Retrieved on 29/07/2014.
http://www2.unicef.org:60090/wash/index_schools.html. Accessed on 01/02/2014
Kenya National bureau of statistics (KNBS) 2008. Well being in Kenya. A
socioeconomic profile June 2010.
Kenya National bureau of statistics (KNBS) 2009, Kenya Demographic and Health
Survey, and ICF Macro.2010. 2008-09: Calverton, Maryland, USA: KNBS and ICF Macro.
Leedy, P., &Ormrod, J., 2005. Practical research: Planning and design (8th Ed.). Upper
Saddle River, NJ: Prentice Hall (http://iisit.org/Vol6/IISITv6p323-337Ellis663.pdf),
Accessed on 05 Sep, 2014.

Liu L,Johnson HL, Cousins S,Perin J et al.,Child Health Epidemiology Reference Group
of WHO and UNICEF. Global and regional, and national causes of child mortality; an
updated systematic analysis for 2010 with time trends since 2000. Lancet.2012 Jun
9;379 (9832): 2151-61.

Matthew C. Freeman, Hubert Department of Global Health, Center for Global Safe
Water, Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE, CNR
2027, Atlanta, GA 30322, USA. E-mail: mcfreem@emory.edu Assessing the impact of a
school-based WT, hygiene and sanitation program
MOH (2007). National Environment and Sanitation Policy, July 2007, Nairobi p6.
Rufus C. E. Eshuchi (2013). Promoting hand washing with soap behavior in Kenyan

schools: learning from puppetry trials among primary school children in Kenya (PhD
thesis report).

25

The National Environmental Sanitation and Hygiene Policy (NESHP, 2007). Ministry of
Health, Division of Environmental Health, July 2007.
UN (2012). The Millennium Development Goals Report 2012. International Decade for
Action

Water

For

Life

2005-2015.

Data

retrieved

from:

http://www.un.org/millenniumgoals/pdf/MDG%20Report%202012.pdf. On 09/02/2014.
UN Inter-agency Group for Child Mortality Estimation, report 2011
UNICEF (2010a). WASH Annual Report. Author: New York.
UNICEF (2011). Levels & Trends in Child Mortality: Estimates Developed by the
UNICEF 2009. Child Friendly schools initiative in Mozambique, Annual field
assessment report, February 2009.
UNICEF. (2010). Raising Clean Hands: Advancing Learning, Health and
Participation through WASH in Schools. New York.
UNICEF 2012. Raising Even More Clean Hands. New York. Available at:
http://www.unicef.org/wash/schools/files/Raising_Even_More_Clean_Hands_Web_17_
October_2012%281%29.pdf. Accessed in august 2014.
UNICEF/WHO (JMP 2012). Progress on drinking water and sanitation, update 2012.
http://www.unicef.org/media/files/JMPreport2012.pdf. Accessed on 21 July 2014.
Washplus/USAID2013.http://www.washplus.org/sites/default/files/wash_nutrition
2013.pdf. www.unicef.Org/Kenya
WHO (2013). Media Centre, diarrheal disease Fact sheet N330 April 2013. Available
at: http://www.who.int/mediacentre/factsheets/fs330/en/. Accesses on July 2014.
www.africalightchristian.org/index.php. Retrievedon06/08/2014.
www.leeonenessfoundation.com/projects/kawangware). Retrieved on 03/08/2014.
Fewtrell, L. K. (2005). Water, Sanitation and Hygiene Intervention to reduce
26

diarrhea in less developed countries: A systematic review and Meta-analysis.

Lancet Infectious diseases.

27

APPENDIX I

Letter of Introduction

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

28

APPENDIX I: SCHOOL QUESTIONNAIRE FORM

Part I: Demographic information

(The interviewee is the head teacher or health teachers)
1. Form serial No:
2. Division:
3. School Name:

_________________________
_________________________________.
_____________________________________

4. No of male staff_______5. No of female staff_______6. Total no of staff_________

7. No. Of boys__________ 8. No of girls____________ 9. Total No of pupils________

Part II: Availability and Access to safe drinking water

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

10. What are the sources of drinking water for the children while in school?
1. Brought from home
2. Tap water at school
3. From borehole at the school
4. From a dug well at the school
5. Other (specify)

Part III: Availability and access to sanitation facilities

11. What type of sanitary facility does the school have? (Ask and observe)
1. Flush toilet
2. VIP latrine
3. Ordinary pit latrine
4. Other (Specify)..
12. If a pit latrine, what kind of floor does it have?
1. Cemented
2. Earth (soil)
3. Wooden
4. Other (pecify).
13. What is the general cleanliness of the flush toilet facility (ies)?
Sex
No. Of No. Clean No. Dirty
Adequate
toilets
Boys
Girls
Total
No.

29

Not adequate

Criteria: Dirty- If not flashed, blocked, presence of fecal matter outside the toilet
14. What is the general cleanliness of the pit latrine facility (ies)?
Sex
#of pit
# Clean
# Dirty
Adequate
latrines
Boys
Girls
Total
No.

Not adequate

Criteria: Dirty- If presence of dirty matter on the floor, on the wall or outside the pit
latrine.
19. Who cleans the toilets?
1. School children
2. School workers
3. Other (specify).
20. How often are the toilets cleaned?
1. Once a day
2. Twice a day
3. Once a week
4. Twice a week
5. Other (specify)

Part IV: Provision and access to hand washing facilities

15. Is there any hand washing facility (ies) near the toilet(s)?
1. Yes
2. No
16. If yes to question 15 above, what type of hand washing facility? And how many?
1. Tap water_____________
2. Hand washing basin_________
3. Leaky tins___________
4. Others:
Specify_______________________________________________
17. Observe availability of water (in HW Facilities)
1. Available
2. Not available

18. Is there any soap for washing hands?

30

1. Yes
2. No

Part V: Provision of hygiene education and Environmental sanitation

23. Do the school provide Hygiene /health education

1. Yes
2. No
24. How often do you give hygiene education
1.
2.
3.
4.

Every Day
Once a week
Once a month
Other (Specify)__________________________________

21. Nature of school playground (observation)

1. Earth/ dusty ground
2. Marram covered ground
3. Grass covered ground
4. Other form of cover
Specify________________________________________
22. How is the solid waste (from school) disposed off? (+observation)
1. Composite pit
2. Open burning
3. Burying
4. Indiscriminate dumping (open dumping)
5. Others (specify) __________________________
23. Do you have specific school cleaning day?
1. Yes
2. No
24. How often is the school compound cleaned?
1.
2.
3.
4.

Every week
Every two weeks
Every month
Other (Specify)____________________________

Name of Interviewer: _________________________________

Signature:_________________ Date:______________________
31

APPENDIX II: PUPILS INTERVIEW QUESTIONNAIRE

Part II: Availability and Access to safe drinking water

1. What is the main source of water at home?
1. River
2. Spring
3. Piped water
4. Bore hall// well
5. Vendors
6. Others(specify) __________________________
2. Do you do anything to treat or make water safe for drinking?
5. Yes
6. No
3. If yes, what do you do to make water safe for drinking?
1. Boil always
2. Boil sometimes
3. Filter
4. Add chemicals (disinfect) such as water guard
5. Others (specify)..

Part III: Availability and access to sanitation facilities

4. Do your family have a latrine/ toilet at home?
1. Yes
2. No
5. If yes, what type?
1. Family pit latrine
2. VIP latrine
3. Water closets (WC)
4. Other (specify)____________________________
6. Do you share your toilet with others?
1. Yes
2. No

Part IV: Provision and access to hand washing facilities

32

7. Is there hand washing facility in your school?

1. Yes
2. No
8.If the answer to the above question is yes, do you use the facilities?
1. Yes
2. No
9. If No, why?
1.
2.
3.
4.
5.

Due to long queue at the facilities

Too high for young children
Mostly no water in the facilities
The area is muddy, dirty and not convenient.
Other reasons (Specify)____________________________

Part IV: Hygiene /health education absorption and practice

10. When do you wash your hands?
1.
2.
3.
4.

____________________
____________________
_____________________
______________________

11. Why do you wash your hands before eating?

1. To feel good by being clean
2. Preventing diseases
3. Other (specify)..
12. Do you use soap when washing hands in school?
1. Yes
2. No
13. If yes, check availability of soap, ash.. at the HWfacilities
1. Available
2. Not available
14 .Should fruits be washed?
3. Yes
4. No
15. Do you wash fruits before eating?
33

1. Yes
2. No
16. If no to question 9 above, why not?
1. Lack of water
2. No need to wash
3. Other (specify)_______________________
17. Have you been sick in the last two weeks?
1. Yes
2. No
18. If yes, what were you suffering from?
1. Diarrhea
2. Cough
3. Stomach aches
4. Headache
5. Other (specify)____________________________
19. Did you go for treatment?
1. Yes
2. No
20. If no, why?
1. I was not too sick
2. I bought medicine
3. Lack of money
4. Other (specify)____________________________
21. Do you wear shoes while in school? (Observe)
1. Yes
2. No
22. How many times do you brush your teeth in a day?
1. Once
2. Twice
3. Not even daily
23. How many times in a day do you take a bath / shower?
1. Once a day
2. Twice a day
3. Every other day
4. Twice a week
5. Once a week
24. Do you wear clean clothes? (Observe)
34

1. Yes
2. No
25. Do you cut and clean your fingernails? (Observation)
1. Yes
2. No
26. Is your hair well kept? (Observation)
1. Yes
2. No
27. Mention at least two diseases which can be avoided by using latrines?
1. __________________________
2. __________________________
28. Mention at least one parasites which can be avoided by wearing shoes?
1. __________________________
2. __________________________

Name of the interviewer ________________________________________________

Signature:
_________________________________________________
Date:
________________________________________________
Note:
At least two diseases: Diarrhea, cholera, Typhoid, Bilhazia, Dysentry
At least two parasites: Jiggers, Hookworm

35

APPENDIX 3: MAP OF KAWANGWARE WARD

36

Appendix 4: Time Frame

Activity
Proposal approval
Recruitment of research assistants & training
Pretesting of data collection tools (pilot study)
Actual data collection from schools
Data entry and analysis
Report writing and submission of 1st draft
Submission of 2nd draft report
Defense of the thesis report
Production of final revised copies

DECEMBER

JANUARY

FEBURARY

MARCH

Appendix 5: Budget
Item Description
Research assistants
Fuel
Stationery
Typesetting

Quantity
4 NO
500 litres
10 reams
100 pages

computation
4x1000/=x 5days
500x112/=
10x500/=
100x40/=
37

Total Amount
20,000
56,000
5000
4000

APRIL

Printing
Binding
GRAND TOTAL

2000 pages
10 copies
KSHS.

2000x10/=
10x500/=

38

20,000
5000
129,900