1. Repeat formative research to inform
design of behavior change interventions
for ‘F’ and ‘E’ of the SAFE strategy during
the rainy season in Oromia, Ethiopia
Supervisor: Mrs. Katie Greenland
MSc Candidate: Katina Sommers
Repeat Formative Research to Inform
Design of Behavior Change
Interventions for ‘F’ and ‘E’ of the
SAFE Strategy During the Rainy
Season in Oromia, EthiopiaSupervisor: Mrs. Katie Greenland
MSc Student: Katina Sommers

2. Overview
 Project Description
 Rationale
 Aims & objectives
 Methodology
 Study site
 Key Findings/Results
 Comparison of dry and rainy seasons
 Potential Intervention Approaches
 Questions & Discussion

3. Rationale
 Trachoma in Ethiopia:
 ~80% of blindness preventable
 74,995,468 people at risk
 SAFE strategy, ‘F’ and ‘E’:
 High quality data lacking
 Formative research, dry season (DS), January 2016:
 Identified key sub-optimal hygiene and sanitation behaviors
 Suggested opportunities for change
 Repeat formative research, rainy season (RS), July
2016:
 Do hygiene and sanitation behaviors vary by season?
 Explore suggested opportunities for change

4. Aims
 This formative research study aimed to:
 Document rainy season hygiene and sanitation-
related practices which may lead to an increased
risk of trachoma
 Explore potential behavioral interventions to
improve these practices in Oromia, Ethiopia

5. Objectives
1. Document where and when behaviors of interest* occur
and who carries them out through direct observations at key
times
2. Investigate possible drivers of key behaviors and factors
inhibiting these practices
3. Explore community perceptions of potential intervention
strategies to influence current practices
4. Compare findings from this study, conducted in July 2016
during the rainy season, with findings from the original
formative research, conducted in January 2016 during the dry
season, to determine how behaviors of interest vary by
season
* Behaviors of interest: defecation/stool disposal practices: type of latrines used, location of defecation and disposal of child

6. Methodology
 Mixed methods
 In-home observations (n=10)
 Socio-demographic surveys (n=10)
 Post-observation interviews (n=10)
 Focus group discussions (n=6)
 Key informant interviews (n=6)
 Analysis
 Field notes
 Transcriptions
 Thematic analysis

7. Thematic Analysis

8. Study Site: Wera Jarso, Oromia
 Rural, pastoralist, low literacy
 60.26% rural pop. using unimproved water
source
 96.83% rural pop. no bathing facility

9. Study Site: Trachoma
Prevalence
Trachoma Atlas: Ethiopia Country Profile

10. Characteristics of Observed
Households
 7/10 households repeated
 Discrepancies in HH size, water/person/day,
human feces in compound
*Blacked out columns are HHs from dry season which were not re-visited. Yellow columns represent dry season. Blue
columns represent rainy season. **+=low; ++=moderate; +++=strong

11. Typical Compounds

12. Key Findings 1: Sanitation
 Latrines
 Pit latrine at 5/10 HHs, clustered by kebele
 Poor example of improved sanitation at community
level
 Open defecation
 Common practice
“Even if they have the latrine they don’t use. They prefer
open defecation.”
 Animal feces widespread in compound
 Drivers of behavior (↓ latrine usage): odors,
disgust, privacy, access
 Drivers of behavior (OD): odors, habit, too busy

13. Sanitation
Above: Young child
open defecating in
immediate compound,
adjacent to living
structure
Below/Right:
Examples of
poorly
constructed HH
latrines

14. Sanitation Comparison

15. Key Findings 2: Water
 Water scarcity “biggest challenge”
 Water pump 5-15minute one-way walk
 Wait time under 5minutes
 Collection of rainwater
 Used for all activities except for cooking and drinking
 Use
 Cooking*
 Washing
 Rinsing dishes
 Drinking
“Lack of water is not a challenge but lack of
knowledge and awareness [are.]”

16. Water Collection
Left to right: Typical water point; Child ‘playing’ with water; Rainwater collection/storage
container

17. Water Point Collection
Comparison
0
20
40
60
80
100
120
HH1 HH2 HH3 HH4 HH5 HH6 HH7 HH8 HH9 HH10
Litersofwatercollected/day
Households
Dry Season Rainy Season

18. Water Comparison

19. Key Findings 3: Hygiene
 Face washing
 9/18 children FW during observation, 6/9 with soap
 faces of young children often left unwashed for hours
 Handwashing
 Key moments
 morning washing routine
 before & after eating
 while cooking
 prior to leaving the compound
 after returning from fieldwork
 Absent after
 wiping nasal/ocular discharge
 handling feces (human/animal)

20. Key Findings 3: Hygiene
(continued)
 Bathing & Laundry
 Increased
 Dirty from fieldwork
 Decreased
 Children not in school (bathing)
 Too cold
 Too busy working in fields
 “Double burden”
 Soap: 8/10 HHs, sporadic use
 Drivers of behavior: status

21. Typical Washing Routine
Hands
Arms
Face

22. Hygiene Comparison

23. Key Findings 4: Sleeping
 Youngest child sleeps with parents
 Older children share mats on floor
 Pillow cases not used
 Pillows and blankets not shared with more
than one other family member
 No variation in seasonal practices/behaviors

24. Key Findings 5: Flies
 Widespread in compounds
 Drawn to faces of youngest children,
regardless of presence of discharge
 Absent during rainfall, heavy smoke, early
morning
 Not typically swatted from faces
 Most flies in month of May
 No seasonal variation noted between seasons
 Drivers of behavior: shame, nurture

25. Flies
Left: Presence of flies with significant nasal discharge
Middle: Presence of flies with little nasal discharge
Right: Absence of flies with significant nasal discharge

26. Key Findings 6: Health
 Rumors:
 “Evil eyes,” vaccinations, azithromycin death,
trachoma genetic
 Barriers:
 Cost, distance, lack of trust of health care
professionals
 Trachoma knowledge:
 5/10 HHs unable to describe trachoma, some had
been treated with MDA

27. Intervention Design Principles
 Successful Interventions
 Multi-faceted
 Simultaneously target multiple trachoma
transmission routes
 Integrate into the pre-set daily routine
 Address the major barriers to optimal hygiene and
sanitation practices
 Feasible
 Acceptable
 Affordable for users

28. Potential Interventions
 Sanitation:
 Community Led Total Sanitation
 Monetary fines for OD, failure to construct latrine
 Water:
 Collect free-falling rainwater
 Construction of water tank
 Hygiene:
 Integrate fathers and siblings into daily washing routine
 Religious leaders and WASH committee members as health educators
 Community events/education programming for school-aged children during
school holidays
 Sleeping:
 Easy wash/quick-dry pillow or pillow case material
 Flies:
 Mesh covering to protect faces while sleeping
 Fly traps
 Wearable repellants
 Repellant dip for accessories or clothing
 Repellant soap/creams

29. Questions and Discussion
Thank You!
Amesegenalehu
Contact Information:
Katina Sommers MSc Candidate,
LSHTM
Katina.Sommers@gmail.com
QUESTIONS &
DISCUSSION