Effectiveness of Community-Led Total Sanitation Activities on Selected Health Outcomes among Children Aged Below Five Years in Kinango Sub-County, Kwale County, Kenya

Abstract

A third of the population globally do not have access to water and sanitation. In Kenya, 55% of the total population does not have access to water and proper sanitation. This has contributed to sanitation related morbidity and mortality among children below the age of 5 years. In an effort to address the problem the Community-Led Total Sanitation (CLTS) approach has worked well in various set-ups. This study aimed to determine the effectiveness of CLTS on selected health outcomes (nutrition status, diarrhea and anemia) among children aged below 5 years in Kinango Sub-County, Kwale County, Kenya. This was a quasi-experimental comparative study with intervention (CLTS among 405 households in 5 villages) sites and control (non-CLTS among 402 households in 5 villages) stes. Anthropometric and haemoglobin measurements were undertaken at baseline and end-line. In addition, an entry and exit questionnaire was administered to collect data on socio-demographic characteristics, knowledge on CLTS practices and on the frequency of experiencing diarrhea among the children <5years. Qualitative data were collected through key informant interviews (KIIs) and Focus group discussions (FGDs). Data were analyzed using SPSS IBM version 22.0. Descriptive statistics were used to explore insights in data. Association between variables was assessed using both chi-square and multivariate logistic regression analysis. The mean difference of health outcomes between CLTS and non-CLTS sites was done using Chi-square test. Binary logistic regression and Poisson regression were used to identify predictors of latrine ownership and morbidity. Qualitative data was summarized using thematic analysis. At baseline survey, out of 402 children, 181 (40.02%; 95% C.I=40.1-50.0) were malnourished in the control group while 221 (54.98%; 95%C.I=50-60) had no malnutrition. On the other hand, out of 405 children, 173 (42.72%; 95%C.I:37.8-47.7) had malnutrition while 232 (57.28%; 95%C.I:52.3-62.2) had no malnutrition. There was no significant difference in nutrition status for children in the control and intervention group (χ2=0.44, df =1, p=0.55) at baseline. Chi-square statistics indicated that there were significantly (χ2=31.2, df =1, p=0.00) more children without malnutrition among the intervention group compared to the control group at end-line. Morbidity for diarrhea was assessed among children below 5 years. At baseline, 230 (57.2%; 95% CI: 52.36-62.04) out of 402 children in the control arm were reported to have experienced diarrhea in the last 2 weeks while 172 (42.8%; 95% CI: 37.96-47.63) had no reports of diarrhea. During the same period, 213 (52.6%; 95% CI: 47.74-57.66) out of 405 children in the intervention arm were reported to have experienced diarrhea in the last 2 weeks while 192 (47.4%; 95% CI: 42.54-52.26) had no reports of diarrhea. Hence, there was no significant difference (χ2=3.083, df=1,p=.079) in the occurrence of diarrhea among children in the control arm compared to the intervention arm at baseline. At endline; 198 (49.3%; 95% CI: 45.0-54.6) out of 402 children were reported to have had diarrhea while 109 (26.9%; 95% CI: 22.83-31.37) out of 405 children in the intervention arm were reported to have had diarrhea. Consequently, there were significantly (χ2=44.73, df=1, p<.001) fewer cases of diarrhea reported among children in the intervention arm compared to the control arm at endline. Awareness on CLTS was a predictor of diarrhea occurrence. Children from households that were aware of CLTS were 55% less likely to present with diarrhea as compared to those living in households that had never heard of CLTS (p<0.001). For anaemia, 89 (22.14%; 95% CI: 18.2-26.5) out of 402 children in the control arm were anaemic while 313 (77.86%; 95%CI: 73.5-81.8) were not anaemic. For the intervention arm, 94 (23.21%; 95%CI: 19.2-27.6) out of 405 children, were anaemic while 311 (76.79%; 95% CI: 72.4-80.8) were not anaemic. There were no significant differences (χ2=0.079, df =1, p=0.78) in the proportion of children that were anaemic in the control arm compared to those within the intervention arm at baseline. At endline, 98 (24.38%; 95% CI: 20.3-29.9) out of 402 children in the control arm were anaemic while 304 (75.62%; 95%CI: 7 1.1-79.7) were not anaemic. Conversely, 38 (9.38%; 95% CI: 6.7-12.7) out of 405 children in the intervention group were anaemic while 367 (90.62%; 95% C.I=87.3-93.3) were not anaemic. Consequently, the proportion of children without anaemia was significantly (χ2=31.3, df =1, p=0.00) higher in the intervention group compared to children in the control group. Latrine ownership was associated with CLTS implementation (AOR = .29, 95% CI = 0.16- 0.53, P< 0.001). Indicators for socio-economic status successfully predicted latrine ownership, the higher the socio-economic status, the higher the probability of owning a latrine. Households that had settled in their own land were two times more likely to own a latrine compared to those without (OR=2.58, 95%, CI: 1.80-3.70, p<.001). Households in the control arm were 53% less likely to own a latrine as compared to those in the intervention arm. Implementation of CLTS, land ownership, type of housing and CLTS knowledge were significant predictors of latrine ownership. This study shows that socio-behavioral interventions can substantially increase access to sanitation facilities in a rural setting. Additionally, CLTS implementation has been shown to improve water, hygiene and sanitation (WASH) practices and subsequently reduce malnutrition, diarrhea and anemia in children aged below 5 years. It is recommended that county governments should scale up CLTS services in areas where open defecation is still a challenge.