BackgroundShared facilities are not recognised as improved sanitation due to challenges of maintenance as they easily can be avenues for the spread of diseases. Thus there is need to evaluate the quality of shared facilities, especially in informal settlements, where they are commonly used. A shared facility can be equated to a common good whose management depends on the users. If users do not work collectively towards keeping the facility clean, it is likely that the quality may depreciate due to lack of maintenance. This study examined the quality of shared sanitation facilities and used the common pool resource (CPR) management principles to examine the determinants of shared sanitation quality in the informal settlements of Kisumu, Kenya.MethodsUsing a multiple case study design, the study employed both quantitative and qualitative methods. In both phases, users of shared sanitation facilities were interviewed, while shared sanitation facilities were inspected. Shared sanitation quality was a score which was the dependent variable in a regression analysis. Interviews during the qualitative stage were aimed at understanding management practices of shared sanitation users. Qualitative data was analysed thematically by following the CPR principles.ResultsShared facilities, most of which were dirty, were shared by an average of eight households, and their quality decreased with an increase in the number of households sharing. The effect of numbers on quality is explained by behaviour reflected in the CPR principles, as it was easier to define boundaries of shared facilities when there were fewer users who cooperated towards improving their shared sanitation facility. Other factors, such as defined management systems, cooperation, collective decision making, and social norms, also played a role in influencing the behaviour of users towards keeping shared facilities clean and functional.ConclusionApart from hardware factors, quality of shared sanitation is largely due to group behaviour of users. The CPR principles form a crucial lens through which the dynamics of shared sanitation facilities in informal settlements can be understood. Development and policy efforts should incorporate group behaviour as they determine the quality of shared sanitation facilities.

Pediatric diarrheal disease remains the second most common cause of preventable illness and death among children under the age of five, especially in low and middle-income countries (LMICs). However, there is limited information regarding the role of food in pathogen transmission in LMICs. For this study, we examined the frequency of enteric pathogen occurrence and co-occurrence in 127 infant weaning foods in Kisumu, Kenya, using a multi-pathogen PCR diagnostic tool, and assessed household food hygiene risk factors for contamination. Bacterial, viral, and protozoan enteric pathogen DNA and RNA were detected in 62% of the infant weaning food samples collected, with 37% of foods containing more than one pathogen type. Multivariable generalized linear mixed model analysis indicated type of infant food best explained the presence and diversity of enteric pathogens in infant food, while most household food hygiene risk factors considered in this study were not significantly associated with pathogen contamination. Specifically, cow’s milk was significantly more likely to contain a pathogen (adjusted risk ratio = 14.4; 95% confidence interval (CI) 1.78–116.1) and more likely to have higher number of enteric pathogen species (adjusted risk ratio = 2.35; 95% CI 1.67–3.29) than porridge. Our study demonstrates that infants in this low-income urban setting are frequently exposed to diarrhoeagenic pathogens in food and suggests that interventions are needed to prevent foodborne transmission of pathogens to infants.

BackgroundSymptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya.MethodsThis is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean.ResultsThe primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination.ConclusionTo our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children.Trial registrationThe trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114).

Unlike most quantitative studies that investigate decision-making on investing in sanitation, this study adopted a qualitative approach to investigate decision-making on shared sanitation in the informal settlements of Kisumu city, in Kenya. Using a grounded theory approach, landlords and tenants were interviewed to identify sanitation decisions, individuals involved in decision-making and factors influencing decision-making. The results indicate that the main sanitation decisions are on investment, emptying, repair and cleaning. Landlords make investment, emptying and repair decisions, while tenants make cleaning decisions. Absentee landlords are less involved in most decision-making compared to live-in landlords, who rarely consult tenants in decision-making. Tenants make decisions after consultations with a third party and often collectively with other tenants. Sanitation interventions in informal settlements should thus, target landlords and tenants, with investment efforts being directed at landlords and maintenance efforts at tenants.

Lack of sanitation facilities is a common occurrence in informal settlements that are common in most developing countries. One challenge with sanitation provision in these settlements is the cost and financing of sanitation. This study aimed at estimating the cost of sanitation, and investigating the social and economic dynamics within Kisumu’s informal settlements that hinder provision and uptake of sanitation facilities. Primary data was collected from residents of the settlements, and using logistic and hedonic regression analysis, we identify characteristics of residents with sanitation facilities, and estimate the cost of sanitation as revealed in rental prices. Our study finds that sanitation constitutes approximately 54% of the rent paid in the settlements; and dynamics such as landlords and tenants preferences, and sharing of sanitation facilities influence provision and payment for sanitation. This study contributes to general development by estimating the cost of sanitation, and further identifies barriers and opportunities for improvement including the interplay between landlords and tenants. Provision of sanitation in informal settlements is intertwined in social and economic dynamics, and development approaches should target both landlords and tenants, while also engaging various stakeholders to work together to identify affordable and appropriate sanitation technologies.

Informal settlements are a common occurrence in developing countries. Each settlement, however, has unique living conditions which require improvement efforts that are specifically tailored to the settlement. This study, carried out in Kisumu's informal settlements, had two aims: to describe living conditions and to propose areas of improvement within the settlements. The study adopted two approaches: the living conditions framework and the multi-dimensional poverty index. Results indicate that deprivation is widespread at the individual and housing unit level, but the settlements are served with public services such as schools and health centres which residents can access. At the compound level, compounds lack infrastructural services such as water, sanitation and solid waste disposal, and where they are available, these services are shared. This study highlights the importance of basic service provision, upgrading of housing and supporting of existing income-generating opportunities within the settlements. Development efforts should involve all stakeholders, including landlords, tenants, community groups and governmental and non-governmental organisations.

Shared sanitation facilities (SSFs) have contributed considerably to sanitation access in many low-income settlements. While many SSFs are of unacceptable quality, others have been found to be a hygienically safe and a socially and economically viable sanitation option. Within its framework, the WHO/UNICEF Joint Monitoring Programme (JMP), evaluating progress on the Sustainable Development Goals, considers shared sanitation as ‘limited sanitation’. Overall, there is uncertainty about the criteria to distinguish between unacceptable and acceptable quality of SSF. In our study, we used a user-centred qualitative approach in low-income urban settlements in Kumasi (Ghana), Kisumu (Kenya) and Dhaka (Bangladesh) and conducted 17 focus group discussions to evaluate how SSF users define the quality of an SSF and which aspects they consider as essential priorities for good-quality SSF. In a descending order, the user priorities identified are: immediate water access, cleanliness, gender-separated toilets, flush toilets, lighting for use at night, lockable/functional doors, tiling, handwashing stations and privacy. This list can serve as input to the sanitation guidelines, local building codes and the establishment of minimum national sanitation standards. SSFs that meet these minimal criteria can then be promoted as an incremental step when individual household facilities are not feasible.

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city's population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6-9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food.