1. Impact of Hygiene Training and
Promotion on Health Outcomes and
Facility Usage in an Urban Slum
By Dr. Renée A Botta and
Dr. Karen C. Loeb
University of Denver

2. Kenya & Kibera
• About 34% of Kenyans live in urban
areas, with approximately 2.5 million
living in Nairobi.
• The urban poor make up 55% of Nairobi’s
total population and occupy 5% of the
total residential land area.
• Kibera is an informal settlement situated
on the southwestern part of the city of
Nairobi.
• The square mile of Kibera comprises 11
villages and is home to over half a million
people living in slum conditions of single
rooms mostly made of mud and
corrugated iron sheets.

3. Poor Sanitation, water quality and hygiene
increase child mortality
• About 4 billion cases of diarrhea per
year cause about 1.8 million deaths,
mostly among children.
• Diarrhea is the second largest killer of
children, accounting for
approximately 21% of deaths of
children under 5.

4. Kibera Informal Settlement
(Nairobi, Kenya)
• Unsafe water, inadequate
sanitation and poor hygiene
cause 88% of diarrheal cases
according to The World Health
Organization (WHO).
• In Kibera, the mortality rate for
children under 5 is 19%.
The average under-five child mortality rate
across eight informal settlements of
Nairobi, Kenya, is 35% higher than the
national figure. In some of the slums, child
mortality rates are more than twice the
rural figure.

5. Our solution
Research indicates investment in hygiene promotion,
sanitation and water services is the most cost-effective
way to reduce child mortality.
Every US$1 spent on improving water supply and sanitation
produces economic gains of at least US$5 and perhaps as
much as US$28, depending on local circumstances.
Adding hygiene promotion can double the impact of
sanitation facilities alone
We believe the high failure rate for adequate wat/san is a
direct result of settling merely for the construction of
facilities as the desired outcome, which is why we use a
multi-faceted approach that links entrepreneurship,
business processes and planning, governance and hygiene
promotion to improved access to water and sanitation.

6. Project Background
Global WASHES is a community-based research collaboration of
University of Denver (DU) faculty and graduate students, Nairobi-based
water and sanitation organization Maji na Ufanisi, the Rotary Club of
Denver Southeast, and faculty and students from universities in
Nairobi.
Our first goal is to develop and test a model of sustainable and scalable
water and sanitation (wat/san) facilities through research and capacity
building in Kibera, an informal settlement in Nairobi, Kenya.
Our second goal is to maximally empower Kiberans as wat/san
advocates, colleagues, entrepreneurs, and facility managers.
We have 8 facilities in the Silanga Village of Kibera, originally funded by
a substantial 3-H Grant from Rotary International.
We also have new facilities funded by the Hungarian Embassy and the
Swedish Embassy in another village in Kibera as well as an informal
settlement in Mombasa.
We work with Community Health Workers (CHWs), which have been
established by the Kenyan Ministry for Public Health & Sanitation, and
with women’s groups and other community based organizations
(CBOs).

7. Areas of Research
• Health and Hygiene Training
• Hygiene KAP (Knowledge, Attitudes, Practices)
• Behavior Change with Theory
• Hygiene Messaging
• Health Communication
• Income Generation as Hygiene Motivator
• Business Planning
• Standard Operating Procedures
• Project Management Oversight
• Usage and Financial (E & R) Records
• Break-Even Analysis for Enterprises
• Positive Net Margin Drivers
• Social Entrepreneurship and Social Franchising
• Sustainability Assessment (3 P’s)
• Local Governance
• Organizational Structure and Dynamics
• Cooperation with Utilities
• Geographical Mapping
• Communication
• Social Capital

8. Hygiene Education & Promotion
 Proper hand washing and water purification is
imperative in reducing diarrhea and ultimately
saving lives
 Research has shown proper hand washing can
reduce the incidence of diarrhea by 40%
 We sought to develop a campaign to promote the
adoption of hygiene behaviors known to reduce
the incidence of diarrhea
 One major problem with using social marketing
behavior change campaigns in developing
countries is that after the intervention is
completed and researchers leave, the falloff rate
for behaviors is very high.
 Some researchers have suggested that sustaining
healthy behaviors requires continuous monitoring
and promotion, as well as ongoing community
mobilization.
 We suggest that linking entrepreneurial hygiene
endeavors is another way to sustain behaviors

9. Our Hygiene Promotion
Participatory, community influenced, train-the-trainer approach
The facilities provide a platform for community-run hygiene trainings.
Hygiene practices tend to fade once promotion ends; however, our model
incentivizes ongoing hygiene promotion and training
Trainers motivated to continue training because can make money selling
liquid soap, water purification, and other hygiene-promotion related
items.
Another key incentive for continuing hygiene practices is the reduction in
diarrhea within the community and the associated socio-economic gain
related to increased attendance at school and work.
Training includes: hygiene and health connections, hygiene practices in
the community, hand washing songs, role playing for peer education and
behavior modeling, making soap, making safe water storage containers,
making hand washing stations, and making hygiene promotion messages.

12. Linking hygiene promotion to social
entrepreneurship
• Formative research conducted to design the hygiene
training to be tailored to the community indicated cost
and control over the environment were the major
barriers to practicing good hygiene
• Thus, we sought to reduce those barriers in sustainable
ways
• Further, the research revealed liquid soap to be cost-
effective to produce and a chlorine water pruification
treatment to be cost effective to sell in individual doses
• Community health workers (CHWs) and community
members were interested in exploring soap making and
water purification sales as small
business/microenterprise ventures.

13. Methods in Brief
• Household surveys conducted to establish baseline and to
learn more about the community for tailoring the hygiene
training
• Baseline health data also collected from AMREF
• Facilities (and thus neighborhoods around facilities)
randomly assigned
• Training conducted
• Messages printed, placed in facilities and given to CHWs
• Post-test household surveys conducted as well as
community observations
• 3 months after post-test household surveys conducted,
post, post-test household surveys conducted, as well as
community observations
• Facility data collected monthly
• Monitoring and evaluation continues
• Health data from AMREF collected quarterly

14. Outcomes: Usage
Total Usage
2500
2000
Number of Uses
1500
Nyando
41
1000 Jola
MSF
Kisinga
500 Okere
Wamunyu
0

15. Outcomes: Usage
Toilet Usage
1600
1400
Number of Uses
1200
1000
Nyando
800 41
Jola
600
MSF
400 Kisinga
200 Okere
Wamunyu
0

16. Outcomes: hygiene practices
Self reported hand washing with soap at key times
significantly increased pre to post test
More importantly, demonstrated proper hand washing also
increased from pre to post test
When take into consideration treatment versus control
facilities (because we randomly assigned training and soap
sales by facility)
Treatment facilities saw average 1 point improvement, whereas
the other five combined saw average 0.3 improvement – we
expected some spillover given the size of the community
Water treatment went from 51% doing nothing and 21%
using chlorine treatment to 32% using chlorine treatment
(post) 18% doing nothing and 36% using chlorine
(post, post)with 26% doing nothing. (change post to post
post in doing nothing is mostly due to those who were
boiling no longer doing anything) These are statistically
significant changes.

17. Outcomes: hygiene practices
Health outcomes also improved pre to post
Diarrhea rates dropped
Self reported and AMREF data
AMREF data not able to tease out by facility so overall
for community compared to control villages
Self reported diarrheal rates dropped more near
treatment facilities than other facilities
Missed work rates dropped
Highest gains near treatment facilities
Falloff? Looking at post versus post post
Small falloff but maintained signif increase from
baseline

18. Conclusions
Increased access to: Improvements in:
• water purification • Diarrhea rates
• soap • Perceived health
• hand washing stations • Missed work
• Proper hand washing
• hygiene training
• Water purification
• hygiene messaging
• Improved toilet
• water usage
• toilets