Effect of eliminating open defecation on diarrhoeal morbidity: an ecological study of Nyando and Nambale sub-counties, Kenya

Open defecation (OD) is defined as defecation in the fields, bushes, and bodies of water or other open spaces. Over a billion people worldwide practice open defecation [1]. In sub-Saharan Africa, an estimated 215 million people engage in open defecation [2]. Only 3 countries i.e. Ethiopia, Angola and Sao Tome and Principe decreased open defecation by 10 % or more between 2005 and 2010. Only Angola is on track to end open defecation by 2015 [2]. An estimated 5.6 million Kenyans defecate in the open [3]. Open defecation predisposes water and food to faecal contamination and may cause diarrhoea and other faecal-oral diseases. In Kenya, approximately 17,100 children under 5 years die each year from diarrhoea, with 90 % of these deaths being attributed to poor water, sanitation and hygiene [3]. Open defecation may also be a risk factor for soil transmitted helminth infections e.g. hookworm, ascariasis and trichuriasis. Open defecation also causes environmental enteropathy which is a sub-clinical disorder characterized by poor nutrient absorption in the gut and associated with stunting in children [4]. An association has been demonstrated between open defecation and stunting in India, with a 10 % increase in open defecation leading to a 0.7 % increase in both stunting and severe stunting [5]. Open defecation is estimated to account for 54 % of variation in average child height among poor and middle income countries, and 65 % when the population density of open defecation is considered [6].

Economic costs of OD practices are contained within the greater estimates of those with poor sanitation. Poor sanitation costs Kenya US$ 324 million with OD estimated to cost US$ 88 million per year [3]. Out of these costs, US$ 244 million is as a result of premature deaths due to diarrhoea and other sanitation related diseases. Expenditure on healthcare including hospitalization is estimated to cost US$ 51 million. Another US$ 26 million is lost productivity due to time spent looking for a place to defecate. A person practicing OD is estimated to spend 2.5 days per year looking for a private location to defecate [3]. Women are more disadvantaged as they also have to look for a private location to urinate as well as accompany young children to defecate [3]. In Kenya, poor are more likely to practice OD with the poorest quintile being 270 times likely to practice OD than the richest [3]. There are also social costs of OD. These include loss of dignity and privacy with the vulnerable sections of the population more affected. This includes the disabled, women and school going girls. Women may be predisposed to gender based violence as they go in search of sanitary facilities especially at night.

Systematic reviews have shown that improving sanitation can reduce diarrhoea diseases by 32–37 % [7‐9]. Kenya launched the open defecation free rural Kenya campaign in 2011. The overall goal was to eradicate open defecation from rural Kenya by end of 2013 [10]. This intervention was spearheaded by the division of environmental health in the ministry of health as well as key non-governmental organizations. The Community- Led Total Sanitation (CLTS) approach was adopted in a bid to eradicate open defecation [11]. Community- Led Total Sanitation (CLTS) was pioneered in Bangladesh in 2000 by Dr Kamal Kar and introduced in Kenya in 2007. It is a participatory methodology for mobilising communities to eliminate open defecation. Communities are facilitated to conduct their own appraisal and analysis of open defecation and take action to become open defecation free. Analysis and appraisal includes mapping areas of open defecation, calculating the amount of faeces produced, medical costs as a result of faecal oral disease burden as well as evoking disgust among the community members due to open defecation. Community-Led Total Sanitation does not provide subsidies and encourages innovation and appropriate local solutions leading to sustainability. A village is declared open defecation free (ODF) once all community members are using latrines and there is no trace of faeces in the environment as verified by a third party. In Kenya, there are three criteria for ODF verification [12]. The first is a complete absence of exposed human faeces within the community. Secondly all households should have access to a latrine which should not predispose users to faecal-oral diseases. Each homestead should have a functional latrine. The squat hole should be covered, the floor should be free of faeces and urine; and the superstructure should provide some privacy. Thirdly all households should have hand washing facility near the latrine. This should be in use and there should be evidence of soap/ash and water. Prior to certification, there is verification of ODF claims by the health workers and village sanitation committee. This is to ensure the village is indeed ODF before external parties can be invited to do ODF certification. In Kenya, certification was initially done by selected non-governmental organizations, the key one being KWAHO (Kenya Water for Health Organization). Currently, there is a move to train local certifiers within each sub-county. This is because certification used to be delayed to due limited capacity of third party certifiers. A typical certification process comprises of three steps. The first being desk study and planning [12]. This includes review of progress reports, forming a certification team and determining sample size. Next is the field visit to collect data. This will involve key informant interviews with natural leaders, government officials, household visits and focus group discussions with community members e.g. women [12]. The certifiers usually take transect walks e.g. through open fields, near water bodies looking for signs of open defecation. Children are also interviewed on where they defecate to corroborate information provided by adults. Each household visited is inspected for a functional latrine with a footpath leading to it to confirm usage. Each latrine is inspected for presence of a drop hole cover, absence of faecal matter on the floor and hand-washing facilities which should show evidence of recent use. The certifiers also verify claims of latrine sharing by households. Lastly there is the data analysis and writing of the certification report which is shared with relevant stakeholders. If a village is certified ODF, then celebrations can be planned [12].

Once certified ODF, the village may celebrate the achievement and erect a signboard or banner detailing the ODF attainment. Celebrations are held at least three months after ODF certification. This is to ensure there is real change before celebration takes place. Prior to celebration, another visit is carried out by third party certifiers. The village sanitation committee continues to be vigilant to ensure ODF is sustained and there is no reversal to open defecation. Attainment of ODF status may be followed by improvement of existing sanitation facilities e.g. through sanitation marketing. As of 2014, CLTS had been implemented in 15 % of villages in rural Kenya and 7 % of villages declared ODF [13]. Counties with the highest number of villages declared ODF were Busia, Kisumu and Siaya. In these counties, 33, 30 and 29 % of villages respectively had been declared ODF [13]. Sanitation and health services in Kenya were devolved after the formation of 47 county governments in 2013. A county is normally divided into sub-counties with the entire country having 265 sub-counties. Out of these only two have been certified ODF. These are Nambale and Nyando. The latter was certified in October 2013 and the former in June 2012 [13]. These are located in Busia and Kisumu counties respectively. The study sought to explore the impact of being declared open defecation free on reported diarrhoea morbidity among infants in these two sub-counties.