Impact of access to Safe Water and PHASE Promotion

on child and Maternal health in Kawempe Division,

Kampala,Uganda

Brenda Achiro1, Denis Kaffoko1, Mtwalib Walude 2, Morrish Ojok 3,

Susan Wandera 4

1African Medical and Research Foundation (AMREF), Uganda Country

Office

& Corresponding author

Brenda Achiro, African Medical and Research Foundation (AMREF),

Uganda Country Office,

Email: Brenda.achiro@amref.org

Abstract

Over view: The Authors are Brenda Achiro, Denis Kaffoko, Susan

Wandera, Morrish Ojok and Mtwalib Walude, Evaluation was

affiliated to African Medical and Research Foundation Uganda.

Brenda Achiro (Brenda.achiro@amref.org) will be the corresponding

Author.

Title: Impact of access to Safe Water and PHASE Promotion on

child and Maternal health in Kawempe Division, Kampala, Uganda.

Background

AMREF Uganda secured funding from the Swedish Broadcasting

Corporation to implement a one-year project, this aimed at

reducing vulnerability to water and sanitation-related diseases.

The objectives were to improve personal hygiene and sanitation

practices at all levels; improve water infrastructure in schools;

increase awareness and action of the community stakeholders to

promote good practices and document best practices and lessons

learned.

Method

The end line survey was descriptive and cross sectional in

nature. Quantitative and qualitative methods of data collection

were used. School and household KAP survey in the 6 schools and

parishes was conducted. 576 respondents were sampled and data was

collected using semi structured tools.

Results

Malaria was the commonest disease 78.2% followed by cough 33.4%,

21.6%- 46.3% got water from Rain Water Harvesting Tanks. 97.7% of

the pupils’ home boiled water at end line compared to 96% at

baseline. 45.6%- 52.1% had fallen sick and missed school. Piped

water 82.3% was major water source followed by protected spring

at 12.5%. 91.3% of households used 5 twenty litre jerry cans in

a day, 94.8% paid for water used. 34.5%-37.7% disposed waste

water in drainage channels and 0.3% dispose waste water in soak

pits.

Conclusion

There was a decrease in the prevalence of all WASH related

diseases, increased water provision, significant reduction in

pupil-stance ratios, increased hand washing and reduced

consumption of unsafe water.

Key Words; Water, pupils, schools, community, Hygiene, diseases, increase, decrease

BACKGROUND

Water Sanitation and Hygiene (WASH) highly impacts on the health

status of the population. Consumption and use of unsafe water

leads to acquisition of diseases which can be classified as water

related. Lack of access to safe water and sanitation services,

coupled with poor hygiene practices, kills and sickens thousands

of children every day, and leads to impoverishment and diminished

opportunities for thousands more. The major water related

diseases that are prevalent in the urban slums of Kampala include

cholera, typhoid, dysentery, diarrhoea and hookworm among others.

ii

Poor sanitation, unsafe water and unhygienic practices contribute

to millions of children morbidity and mortality especially in the

developing world. Water and sanitation-related disease, despite

being preventable, remains one of the most significant child

health problems worldwide (UNICEF, 2010)1.

Poor sanitation, water and hygiene have many other serious

repercussions. Children and particularly girls are denied their

right to education because their schools lack private and decent

sanitation facilities. Women are forced to spend large parts of

their day fetching water. Poor farmers and wage earners are less

productive due to illness, health systems are overwhelmed and

national economies suffer. Without WASH (water, sanitation and

hygiene), sustainable development is impossible.

Project introduction and background

AMREF Uganda secured funding from the Swedish Broadcasting

Corporation (SBC), through AMREF Sweden, to implement a one-year

project “Improving Access to Safe Water and PHASE Promotion in Schools and

Communities in the Slums of Kawempe Division in Kampala City, Uganda”. The

project was expected to commence in September, 2011 and end in

August 2012. The project was designed to cover three (03)

government and three (03) private schools in three (03) parishes

of Kawempe Division in Kampala City, Uganda, namely Kanyanya,

Kawempe I and Mulago II parishes. The baseline survey was

1

iii

conducted in those areas and based on the results of the survey

implementation was done in those areas

The project aimed at reducing vulnerability to water and

sanitation-related diseases among in-school children in Kawempe

Division of Kampala Capital City in Uganda. Through members of

school health clubs (pupils), the project reached out to fellow

pupils in school, their families and the community at large

through education and promotion of good practices in personal

hygiene and sanitation. The project also aimed at enhancing the

capacity of school and community support structures, including

Parents and Teachers Associations (PTAs), School Management

Committees (SMC) and Zone/ Village Health Team (VHT) to practice

and advocate for improved water and sanitation facilities in

schools and their respective communities.

iv

The project goal was to contribute to reduced diseases due to

poor sanitation and unsafe water in Kawempe Division of

Kampala City in Uganda. Project purpose, to strengthen the

capacity of schools in Kawempe Division to prevent water and

sanitation related diseases, Project Objectives Improved

personal hygiene and sanitation practices at school and

community levels using the PHASE and SHC Models, Improved

water infrastructure in six 06 schools in Kawempe Division,

Increased awareness and action of the community stakeholders

to promote good practices in personal hygiene, water and

sanitation in Kawempe Division, Documentation of best

practices and lessons learned from implementation of the

PHASE and SHC models in an urban environment.

METHODS

The evaluation was conducted in three (03) parishes of Kawempe

Division in Kampala City, Uganda, namely Kanyanya, Kawempe I and

Mulago II parishes where the six selected schools three (03)

government and three (03) private are located.

The target population was pupils in the primary school where the

project was being implemented, household heads in the parishes of

v

Kanyanya, Kawempe I and Mulago II. The other target population

was the head teachers/ WASH club patrons, VHTs and Local Council

leaders involved in the project implementation.

End line survey design

This end line survey was descriptive and cross sectional in

nature. It employed both quantitative and qualitative methods of

data collection.

Quantitative data mainly comprised of the knowledge, attitudes

and practices related to Water, Sanitation and Hygiene as

gathered from the respondents. The qualitative data was mainly

from key informants and focus groups discussions.

KAP Survey

A school and household KAP survey in the six target intervention

schools and parishes in Kawempe division, Kampala district was

conducted. The purpose was to assess the level of comprehensive

knowledge, attitudes and practices related to water, sanitation

and hygiene.

Sample Size

The sample size for the KAP survey was determined to enable

computation of population prevalence of knowledge, attitudes and

practices related to water, sanitation and hygiene for each of 6

parishes. It was determined therefore based on the formula for

vi

cross-sectional studies in which the primary outcome is a

proportion. The formula is: [(Z2PQ) D/δ2], where Z is the

standard normal deviate at 95% confidence, P is the estimated

proportion of the surveyed population that has comprehensive

knowledge about water, sanitation and hygiene (estimated at 50 %

based on urban slum sanitation assessment in Kikulu and Basiima

Kikooza slums survey), and δ being the desired precision (at 5%

for this survey). D is the design effect, which is estimated at

1.5, because the sampling was conducted at 2 levels before

reaching the definitive respondent: The computed sample size was

therefore 576 respondents.

Sampling procedures and selection of the respondents

A total of 576 respondents were interviewed. The total sample

size was equally distributed between the two major populations

which implied that there were 288 pupils and 288 household

respondents.

This implies that within each selected school there were 48

pupils sampled and in each school host community, there were 48

respondents.

In each primary school selected for this evaluation, respondents

(pupils) were selected randomly from P.4 – P.6. Respondents from

the host communities were randomly selected from each host

parish.

vii

Data collection procedures

Research assistants and consultant, field coordinator

administered a structured questionnaire to the household level

respondents and the pupils upon seeking consent from the

respondents for the households and teachers for the pupils.

WASH facility assessment

WASH facilities in the schools and communities were assessed.

These included water sources, water purification (Solvatten

technology), sanitary facilities, hand washing facilities and

waste disposal facilities. These were assessed using the

observational checklist.

Data collection method

Observational checklists were used to capture the current state

of the various WASH facilities. The observations were done by the

research assistants .

Process issues analysis

A wide range of issues related to the implementation of the

project were analyzed like criteria of selection of

beneficiaries, strategies and approaches used among others.

viii

Key informants interviews

A total of at least 12 key informants were interviewed in this

end line evaluation survey in both the schools and communities

including:-Head teachers (03), WASH club patrons (03), VHT

members who were part of project implementation (03), PTA/SMC

Chair person (03).

Focus Group Discussions

Four FGDs were conducted. These included 2 in school (consist of

members of the WASH clubs) and two in the community comprising of

VHT and PDCs who were involved in implementation of WASH related

project in Kawempe division.

WASH –related diseases trends analysis

A tool was designed to capture prevalence data from the HMIS

forms from the health facilities that provide health care to the

communities and pupils. The diseases whose data was captured

included:-Cholera, Dysentery, Diarrhea, Eye conditions,

Intestinal worms, Malaria, Skin diseases and Typhoid fever.

Desk document/reports/literature review

This was done to clearly bring out WASH in school context

analysis in relation to the project goal and objectives. It

further looked at:- Current statistics related to WASH (in

general and in schools),Different approaches of WASH promotion

ix

relative to the project approaches ,Factors influencing School

WASH promotion among others.

Data collection tools

Data was collected using semi structured tools that were

developed in consultation with AMREF. These were similar with the

tools that were used at the baseline survey with only relevant

adjustments. These tools include: KAP respondents’ questionnaire,

Key informants discussion guide (Specific to specific

categories), Focus group discussion guide (pupils and Community),

Observational checklist, Desk review guide.

Data Management

For the KAP survey, data entry interfaces were created using Epi-

data Version 3.2 and exported to SPSS version 17 for analysis.

Data was entered by 2 data entry clerks, after which it was

cleaned. A simple analysis of frequencies to derive key target

output indicators was conducted. Using the frequencies generated

the tables, graphs and pie charts were generated. Cross

tabulation was also done and the data was presented in tabular

format. Analysis for any significant relationships between

utilization of the water and sanitation facilities and the

independent variables such socio demographic characteristic of

the respondents, type of water source, and type of sanitary

facility was done. Qualitative data captured from the Key

informants and observational checklists and group discussions was

x

analyzed and incorporated into the report. This data was

thematically arranged in a master sheet in line with the specific

objectives. The qualitative data mostly backed up the

quantitative findings.

Results

The results showed a big decrease in the prevalence of all the

diseases related to WASH in Kawempe and Malaria was the commonest

disease 78.2% followed by cough 33.4% as compared to malaria and

diarrhea by 7.9% and 0.4% respectively at baseline.

A total of 259 pupils were involved in the endline survey

compared to 227 at baseline from the six schools where the SBC

project was implemented. 42.5% of the pupils were from Primary

xi

six, considering the fact that these pupils would be able to

articulate issues and respond to the questions accordingly. This

number was also representative and adequate to allow for

generalization of generated proportions, trends and

distributions.

61.4% of the pupils were females, 56.8% in the age bracket of 11

- 13 years. Majority 73.7% were Baganda. Over a quarter of the

pupils 27.8% were Muslim. Almost equal proportions of the pupils

49.4% and 40.0% said their parents owned and rented the houses

they lived in respectively. A small proportion 16.2% of the

pupils said they stayed in single roomed houses.

Most pupils 89.9% (up from 83.3% at baseline) from all the six

schools mentioned their schools got water from taps. There was a

decrease in the percentage of pupils who said they got water from

boreholes (from 7.9% at baseline to 6.9% at endline) and well

(from 21.6% at baseline to 12.4% at endline). There was an

increase in the percentage of children who said they got their

water from Rain Water Harvesting Tanks (RWHTs) (from 21.6% at

baseline to 46.3% at endline). The increase in the use of RWHTs

was attributed to the provision of RWHTs in these schools by

AMREF.

It was clear that tap stands was the main water source mentioned

by most pupils in the six schools followed by springs and RWHTs.

xii

Compared with the baseline, increase in tap stand use was

observed in Good Times Infant P/S (83% to 93%), Uganda Martyrs

P/S (67.3% to 89.8%), and Kawempe COU P/S (76.5% to 91.9%). There

was a decrease in the number of pupils who said they got water

from wells significantly from Uganda Martyrs P/S (14.3% to 0%),

St. Charles Lwanga P/S (80.6% to 12.4%), St. Martin Mulago P/S

(11.8% to 0%), and Kawempe COU P/S (35.6% to 2.6%). However there

was an increase in use of wells in Good Times Infant P/S (0% to

4.7%), and Kawempe Mbogo Muslim P/S (14.7% to 51%). Kawempe Mbogo

Muslim P/S also had reduced used of RWHTs (24.5% to 18.4%). This

is an indication that despite the intervention, Kawempe Mbogo

Muslim P/S still had a lot of challenges with regard to provision

of safe water. In the other five primary schools, there was

increased use of RWHTs as a water source mainly attributed to the

provision of the RWHTs.

Of all the pupils involved in the end line evaluation, 87.3%

(226/259) said they drunk water at school during school hours

while only 12.7% (33/259) said they never took water at school.

Over half of the pupils (56.2%) from the six schools mentioned

Solvattens as the source of drinking water. There was a

significant decrease in the number of pupils who said they got

their drinking water from the tank (from 25.6% at baseline to

6.2%) and carrying from home (from 25.6% at baseline to 3.1%). In

Kawempe COU P/S, none of the pupils mentioned Solvatten as a

xiii

source of drinking water which could suggest that this school was

not provided with this technology.

It was established that the drinking water was stored in jerry

cans. These jerry cans were provided by AMREF to the schools

alongside the Solvatten units. Two 60 litre jerry cans with

covers were provided in each school for drinking water storage

after boiling using the Solvatten units. In terms of adequacy,

the storage facilities were noted to be inadequate considering

high school populations.

Almost all the children mentioned that they used a cup to draw

water from the jerry can where the water was stored. It was

highlighted from the KIIs that AMREF provided cups (about 60 to

each school) for the children to use for drinking water. The

pupils were guided by the person in charge of the Solvatten

technology to pour water in the cup and drink then return the

cup. This implies that after 60 pupils have taken water in these

cups, they are supposed to be washed and dried before use by the

next 60 pupils.

Over two thirds of the pupils (67.3%) said they stored their

drinking water in Jerry cans at home compared to 60.4% at

baseline. There was also a reduction in the percentage of pupils

who said they stored their drinking water in pots (from 31.7% to

xiv

26.8%). This is an indication if increased water safety as a

result of better storage.

Majority of the storage facilities (95.6%) at endline were

covered compared to 86.8% at baseline. Covering of water storage

facilities is important in reducing the risk of contamination

after boiling. This increase in the proportion of children who

said their water storage facilities were covered is an indication

of increased water safety at household level.

Over two thirds of the pupils (71%) said they sometimes took

unboiled water down from 85.9% at baseline. The greatest

improvement was seen in Kawempe COU P/S (from 100% to 64.7%),

Good Times Infant P/S (from 91.5% to 67.4%), St. Martin Mulago PS

(from 88.2% to 79.2%), and Uganda Martyrs P/S (from 95.9% to

63.3%). Sensitization in these schools targeted promotion of safe

water consumption

Majority of the households got water from tap water systems

thought the percentage of the pupils who mentioned it dropped by

4 points (from 74%). On the other hand, there was an increase in

the proportion of pupils who mentioned the other sources of water

like springs (+1.1%), and RWHTs (+1.8%). Continuous emphasis on

the need to use clean water for all household activities should

be made as it reduces the risk of contracting poor WASH related

illnesses.

xv

4/6 primary school still had pupil stance ratios above the

recommended 40:1 though margins of variation are generally lower.

Some of the changes in variation are due to addition of sanitary

facilities like in St. Martin Mulago P/S and Uganda Martyrs P/S.

However for others like in Kawempe CoU P/S, the changes may be

attributed to changes in pupils’ population since there was no

new facility provided.

Almost all the pupils (99.2%) said they had latrines at home.

Only two pupils (1 from Good Times Infant P/S and 1 from St.

Charles Lwanga P/S) said they never had latrines in their homes.

Both of them said they used their neighbors’ latrine.

More than half of the pupils (54.3%) said they used Ordinary pit

latrines while 40.3% said VIP latrines and only 5.4% said flush

toilets. this is a reflection of the affordability of the

ordinary pit latrines as compared to the VIP and Flush toilets.

Over half of the pupils (53.1%) said their households shared the

latrine they used with their neighbors, a higher proportion than

that registered at baseline (44.1%). This therefore implies that

while sensitizing the communities on issues of hygiene and

sanitation, the whole community should be involved otherwise a

failure in one household to maintain good hygiene and sanitation

may cost other household which share the same facility.

xvi

In the six schools, two movable hand washing facilities were

provided under this AMREF project, one for boys and the other for

girls. In the health talks by the health clubs, hand washing was

highly emphasized though there still some challenges with the

pupils fully taking up the practice of hand washing.

(82.5%) of pupils said they disposed of rubbish in rubbish pits

while 16.7% said they disposed of rubbish in dustbins. This is

not far from the baseline data that showed that 81.3% and 17.4%

disposed of their rubbish in rubbish pits and dustbins

respectively. This suggests that no intervention was directly

linked to waste management in schools.

98.8% (256/259) said they knew the importance of washing hands.

This is only +0.6% from the baseline findings an indication that

the level of awareness among the pupils about the importance of

hand washing was and is high.

Cholera (87.3%), diarrhea (75.7%) and typhoid (52.1%) were the

most known WASH related mentioned by the pupils. Compared to the

baseline data, there are changes in the proportion of pupil who

mentioned cholera (+5.4%), diarrhea (+1.7%), and typhoid (-4.7%).

The average level of awareness for the three commonly known WASH

related diseases (cholera, diarrhea, and typhoid) was 71.7%

compared to 70.9% at baseline. This is a simple measure of

comprehensive knowledge which shows a slight increase.

xvii

The anal cleansing materials used by the pupils at school biggest

proportion of the pupils (66.7%) mentioned that they used toilet

paper this is a significant increment from 53.7% at baseline.

However, toilet paper use in Uganda Martyrs P/S was still very

low (38.3%) with a simple majority of the pupils, 40.4% using

papers from books. This therefore calls for more provision of

toilet paper.

91.6% at baseline said they wash hands after visiting the

latrine. This is a great improvement that is mainly attributed to

the rigorous sensitization and facility provision in these

schools under the AMREF project.

Less than half 45.6%, the pupils down from 52.1% at baseline said

they had fallen sick and missed school in the past term. Malaria

was the commonest illness responsible for pupils’ absenteeism.

Compared with the baseline findings, there was a reduction in the

proportion of pupils who mentioned malaria and diarrhea by 7.9%

and 0.4% respectively.

Over two thirds of the pupils 67.2% of pupils up from 56.2% at

baseline said they talked to their parents and other people at

home about hygiene and sanitation issues they learnt as school.

There was a general increase in the proportion of the pupils who

xviii

said they talked to their parents about hygiene and sanitation

from Good Times Infant P/S, St. Martin Mulago P/S and Kawempe COU

P/S. on the other hand, there was a decrease in the proportions

from Uganda Martyrs P/S and St. Charles Lwanga P/S though the

proportions remained high (above 50%). However just like at

baseline, the proportion of the pupils who talked to their

parents and other people at home remained significantly low in

Kawempe Mbogo Muslim P/S. Children talking to their parents and

other people in their homes about hygiene and sanitation issues

is a form of knowledge diffusion and one of the ways children can

act as change agents.

There was low pupils’ membership in health clubs in Kawempe COU

P/S, Kawempe Mbogo Muslim P/S, and Good Times Infant P/S. On the

other hand, the was high pupil’s membership in Uganda Martyrs

P/S, St. Martin Mulago P/S, and St. Charles Lwanga P/S which

suggested that these clubs were highly promoted among the pupils.

A total of 288 households were involved in this SBC baseline

survey from Kawempe division and their distribution by parish,

these were selected on the basis of the number of schools hosted

by the parish. For example, Kawempe I hosted two schools while

Mulago II hosted only one school.

67.7% of the respondents were females; over two thirds of the

respondents (68.1%) were married. Majority, (64.9%) of the

xix

respondents was Christians while 34.4% were Muslims. Only 3.1% of

the respondents mentioned they had no education. Over a quarter

of the respondents (28.7%) mentioned they had lived in the

village for over five years.

81.9% of the household heads (HH) were male adult. Majority of

the HHs were Christians (67.1%) while 32.4% were Muslims. Only

6.1% of the HHs had no education. Piped water (82.3%) followed

by protected spring (12.5%). These findings indicate an increase

(by 12.6%) of the proportion of households getting water from the

piped water system from the baseline survey with not of the

respondents citing unprotected well as at baseline. Protected

springs were only cited in Kanyanya and Kawempe I parishes.

Compared with the baseline data, there was an increase in the

proportion of households that got water from piped water system

(Kanyanya +8%, Kawempe I +2.6%, and Mulago II +29.1%); this

represents a significant shift to a safer water source option

within the community. With regard to the safety of the water

sources, it was noted that the tap water source was generally

safe as the water had chlorine smell, an indication it was

treated before distribution to the communities by the National

Water and sewerage cooperation.

Over 90% of the households (91.3%) said that they used 5 jerry

cans or less of water in a day. However compared with baseline

data, there was an increase in the proportion of households that

xx

said they used more than five jerry cans of water in a day(from

7% at baseline to 8.7% at endline survey), suggesting an increase

in general household water consumption which would create more

need for water that may lead to increased demand.

Almost all the respondents (94.8%) said that they paid for water

they used in their homes. The as is this expected as most of the

respondents as noted early got their water from tap water systems

that must be paid for. Majority of the respondents (82.1%) said

they paid 200/=. Compared with the baseline data where only 25%

of the respondents then said they paid 200/= for a 20L jerry can

of water, it is clear that there cost of water has become higher.

This is more reason that the communities need to be sensitized on

ways of avoiding water wastage alongside the safe water chain.

Female spouses (mothers) were the ones who used most water in the

household followed by female children. This is again anticipated

as they are the ones who are usually responsible for household

activities like cooking; cleaning and washing that require water.

Compared with baseline findings, the proportion of those who

mentioned female spouse and males spouse had increased (13.1% and

6.6% respectively). Whereas this may suggest increased male

involvement in households WASH related activities, it is

inconclusive.

xxi

About a third of the respondents (33.1%) said both male and

female children were responsible for collection of water in their

households. This therefore implies that the children are the ones

who get more in contact with the water at the water source. This

is almost similar to the baseline survey findings with only a 1%

increment. Over a third of the respondents (34.5%) said female

spouses were responsible for collection of water in their

households compared to the 29.6% at baseline.

Almost two thirds of the respondents (65.3%) said they got their

drinking water from the tap water system, representing a 1.2%

increase from the baseline finding. However, there was a

significant decrease in the proportion of respondents who said

they got their drinking water from household taps.

98.3% (283/288) said they boiled their drinking water while the

rest said they treated chemically with water guard. Since none

of the respondents said they did nothing as was noted by three

respondents at baseline survey. Majority of the household’s

stored their drinking water in plastic jerry cans with covers

91.6% up from 70.4% at baseline survey. There was a decrease in

the proportion of the respondents who mentioned pots and plastic

jerry cans without covers.

Almost two thirds of the respondents (63.6%) said they cleaned

their drinking water storage facility at least twice a week,

xxii

there was an improvement in the methods of cleaning the different

drinking water storage facilities compared to the baseline

findings in that there was more scrubbing and rinsing without

soap.

34.5% of the respondents down from 37.7% at baseline survey said

they disposed their wastewater in drainage channels while only

0.3% dispose their waste water in soak pits. The percentage of

respodents who disposed off their waste water on the road

increased by 5%.

There was a reduction in the proportion of the respondents who

said they poured wastewater on the road in Kanyanya parish while

similar proportions in Kawempe I and Mulago II parishes. Also

there were no soak pits mentioned in Kanyanya and Kawempe I

parishes. The biggest proportion of the respondents (83.3%) used

bathrooms that were located outside the house where they slept.

This is slightly higher than the proportion at baseline survey.

There was no respondent who said their household lacks a bathroom

compared to the 2.1% at baseline survey. For households that said

they had outside bathrooms thus share, over half of the

respondents (53.3%) mentioned children as the ones who took care

of the solid waste disposal in the households.

It is clear that households in Kanyanya parish pay for refuse

collection while a few and none of the households in Kawempe I

xxiii

and Mulago II parishes paid for their solid waste collection and

disposal. This indicates that in Kanyanya there was more private

sector involvement in solid waste collection and disposal while

in Mulago it was purely KCCA.

Majority of the respondents in Kanyanya parish who paid said they

paid less than 1000/= per week for solid waste collection and

disposal while majority of these respondents said they paid more

than 1000/= per week for solid waste collection and disposal from

their homes. This may explain why a smaller proportion of

respondents (15.9%) in Kawempe I parish said they paid for solid

waste collection and disposal compared to the 53.7% from Kanyanya

parish. Half of the respondents (50%) mentioned they dispose

their rubbish at least once every week. This is lower though not

far from the baseline’s 52.7%. However in Mulago II parish, 58.3%

said they disposed of their rubbish every two weeks compared to

the 43.4% and 38.6% in Kanyanya and Kawempe I parish

respectively.

Almost all the respondents (95.1%) said they shared sanitary

facilities with other household. Over half of the respondents in

Kanyanya and Kawempe I parishes share sanitary facilities with 1

– 5 households while over half of respondents from Mulago II

parish shared with more than five households. These are similar

proportion to those seen at baseline survey, an indication that

there had been no improvements over the past one year.

xxiv

Almost all respondents (99.3%) compared to 96.5% at baseline said

they washed their hands after visiting a sanitary facility while

only two respondents (one from Kawempe I and one from Mulago II)

said they did not wash their hands after using a latrine. further

still, 98.6% noted that they washed hands every time they visited

a latrine. compared with baseline survey findings, there was an

increase in the proportions that said they washed their hands

every time they visited a latrine.

Less than half of the respondents 49.3% (Kanyanya 47.4%, Kawempe

I 52.4% and Mulago II 43.8%) said that they had at least one

child in their household studying in a primary school. Of all

the respondents who mentioned that they had at least a child

studying in a primary school, over two thirds, 71.8% said their

children missed school because of some illnesses. This is higher

than the findings at baseline survey where 66.7% of the

respondents who had at least a child in a primary school

indicated that the children had missed school because of some

illness.

Most of the respondents (73.6%) got their treatment from private

clincs while less than a third (26.4%%) got their treatment from

government health centre. Compared with baseline findings, the

proportion of the respondents who sought medical treatment from

private clinics increased from 64.5%.

xxv

More than half of the respondents 51.7% and 52.1% from Kawempe I

and Mulago II respectively said that children talked to their

parents about WASH compared to the 38.9% from Kanyanya parish.

Discussion

The results showed a big decrease in the prevalence of all the

diseases related to WASH in Kawempe and Malaria was the commonest

disease 78.2% followed by cough 33.4% as compared to malaria and

diarrhea by 7.9% and 0.4% respectively at baseline. This was

attributed to increased hygiene education within schools and the

community by several stakeholders in both the private and public

sectors. Cholera (87.3%), diarrhea (75.7%) and typhoid (52.1%)

were the most known WASH related mentioned by the pupils.

xxvi

Compared to the baseline data, there are changes in the

proportion of pupil who mentioned cholera (+5.4%), diarrhea

(+1.7%), and typhoid (-4.7%). The average level of awareness for

the three commonly known WASH related diseases (cholera,

diarrhea, and typhoid) was 71.7% compared to 70.9% at baseline.

Most pupils from all the six schools mentioned their schools got

water from taps. There was a decrease in the percentage of pupils

who said they got water from boreholes and wells also there was

an increase in the percentage of children who said they got their

water from Rain Water Harvesting Tanks (RWHTs) and the use of

RWHTs was attributed to the provision of RWHTs in these schools

by AMREF. It was clear that tap stands was the main water source

mentioned by most pupils in the six schools followed by springs

and RWHTs.

4/6 primary school still had pupil stance ratios above the

recommended 40:1 though margins of variation are generally lower.

Some of the changes in variation are due to addition of sanitary

facilities; the changes may be attributed to changes in pupils’

population since there was no new facility provided. More than

half of the pupils (54.3%) said they used Ordinary pit latrines

while 40.3% said VIP latrines and only 5.4% said flush toilets.

this is a reflection of the affordability of the ordinary pit

latrines as compared to the VIP and Flush toilets.

xxvii

In the six schools, two movable hand washing facilities were

provided under this AMREF project, one for boys and the other for

girls. In the health talks by the health clubs, hand washing was

highly emphasized though there still some challenges with the

pupils fully taking up the practice of hand washing. 98.8%

(256/259) said they knew the importance of washing hands. This is

only +0.6% from the baseline findings an indication that the

level of awareness among the pupils about the importance of hand

washing was and is high. Less than half 45.6%, the pupils down

from 52.1% at baseline said they had fallen sick and missed

school in the past term.

Over two thirds of the pupils 67.2% of pupils up from 56.2% at

baseline said they talked to their parents and other people at

home about hygiene and sanitation issues they learnt as school.

Children talking to their parents and other people in their homes

about hygiene and sanitation issues are a form of knowledge

diffusion and one of the ways children can act as change agents.

Over 90% of the households (91.3%) said that they used 5 jerry

cans or less of water in a day. However compared with baseline

data, there was an increase in the proportion of households that

said they used more than five jerry cans of water in a day(from

7% at baseline to 8.7% at endline survey), suggesting an increase

in general household water consumption which would create more

need for water that may lead to increased demand.Almost all the

xxviii

respondents (94.8%) said that they paid for water they used in

their homes. Majority of the respondents (82.1%) said they paid

200/=. Compared with the baseline data where only 25% of the

respondents then said they paid 200/= for a 20L jerry can of

water, it is clear that there cost of water has become higher.

This is more reason that the communities need to be sensitized on

ways of avoiding water wastage alongside the safe water chain.

98.3% (283/288) said they boiled their drinking water while the

rest said they treated chemically with water guard. Since none

of the respondents said they did nothing as was noted by three

respondents at baseline survey. This also indicates that there

is a remarkable level of awareness about the dangers associated

with consumption of unsafe water.

34.5% of the respondents down from 37.7% at baseline survey said

they disposed their wastewater in drainage channels while only

0.3% dispose their waste water in soak pits. The percentage of

respodents who disposed off their waste water on the road

increased by 5%. This indicated that over the past one year,

there has not been any iprovement in waste water management

practices at community level.

Half of the respondents (50%) mentioned they dispose their

rubbish at least once every week. This is lower though not far

from the baseline’s 52.7%. However in Mulago II parish, 58.3%

xxix

said they disposed of their rubbish every two weeks compared to

the 43.4% and 38.6% in Kanyanya and Kawempe I parish

respectively. This discrepancy presents a clear difference

between places where there is private sector involvement and

where it is lacking.

Almost all the respondents (95.1%) said they shared sanitary

facilities with other household. Over half of the respondents in

Kanyanya and Kawempe I parishes share sanitary facilities with 1

– 5 households while over half of respondents from Mulago II

parish shared with more than five households. These are similar

proportion to those seen at baseline survey, an indication that

there had been no improvements over the past one year.

Most of the respondents (73.6%) got their treatment from private

clincs while less than a third (26.4%%) got their treatment from

government health centre. Compared with baseline findings, the

proportion of the respondents who sought medical treatment from

private clinics increased from 64.5%. This presents a challenge

of under reporting prevalence of such diseases since data from

small clinics is not captured in the HMIS forms that are filled

in by Goernment Health Facilities and big private health

facilties.

xxx

CONCLUSIONS

Poor WASH related disease prevalence and trends in Kawempe

division

In line with the project goal of reducing the prevalence of

WASH related diseases, there was a decrease in the

prevalence of the all the diseases related to WASH in

Kawempe division from 2010/2011 and 2011/2012 as reflected

in the finding. However this decrease cannot be solely

attributed to only this project as the project

implementation period was very short and targeted mainly the

primary schools rather than the communities.

Water sources, safety and the current water infrastructure.

There was increased water access/provision as a result of

construction of a RWHT in each school thus 6 RWHTs in the

six schools.

There is increased access and consumption of safe drinking

water as a result of AMREF’s distribution of 10 Solvatten

water purification containers in each school, drinking water

storage facilities and drinking cups. However these are

still inadequate. The increased consumption of consumption

of safe water is also attributed to the continuous health

education by the SHCs.

Proportion of sanitation facilities (hand-washing stations, dish

drying racks, rubbish pits)

xxxi

There was a significant reduction in pupil-stance ratios in

5/6 schools much as there was no provision of sanitary

facilities under the AMREF project. This is attributed to

the other School WASH stakeholders who provided sanitary

facilities in some schools in this same period. Despite this

decrease in the pupil-stance ratios, sanitary facilities are

still inadequate in most schools as they still had high

pupils-stance ratios above the recommended 40:1 ratio.

Nature and extent of proper waste (solid and liquid) disposal

practices

There was general improvement in cleanliness of the schools.

This is mainly attributed to the good leadership of the SHCs

in the different schools. Other stakeholder intervention

like KCCA’s provision of rubbish collection containers in

some schools contributed to the improved management of solid

waste in the schools.

Awareness levels of schools in matters of hygiene, water and

sanitation

Pupils’ level of awareness of matters related to WASH was

very high mainly due to the health education and

sensitization interventions by the SHCs.

Behavior patterns regarding water habits, proper personal hygiene

and sanitation.

There was increased hand washing practices that is

attributed to AMREF’s provision of HWFs to the schools.

xxxii

There was increased school provision of water and soap to

promote hand washing after latrine use. This is also

attributed to the continuous health education and

sensitization by SHCs

There was increased provision of anal cleansing materials

much as sustainability is still a challenge

There was increased pupils’ sharing of WASH issues learnt a

school with family members. This is an indication that

indeed children can be targeted as change agents within

their homes and the community.

Water sources, safety and the current water infrastructure.

Piped water was still the main source of water in the

community followed by protected spring

There was reduced consumption of water from unsafe water

sourced like unprotected springs.

Water consumption at HH level was high since more than two

thirds of respondents said they used more than 3 jerry cans

of water in a day.

Proportion of sanitation facilities

Shared ordinary pit latrines were the most commonly used

type of sanitary facility in the community.

Behavior patterns regarding water habits, proper personal hygiene

and sanitation

xxxiii

Boiling water is highly embraced in the community. This is

attributed to sensitization of communities about WASH

related issues by HAs

Prevalence of poor WASH related diseases in selected parishes

Malaria was still the commonest disease affecting the

community followed by cough.

Households took their children for treatment at a health

facility when they fell sick and private clinics were

preferred over government facilities.

Acknowledgments

AMREF Uganda is greatly indebted to all the people who made this

paper a success and the almighty God for giving them life and

courage to complete this piece of work.

Competing interests

The authors declare no competing interests.

Authors’ contributions

All the authors have contributed to this manuscript in ways that

comply to the ICMJE authorship criteria. All the authors have

read and approved the final version of the manuscript.

References

xxxiv

1. Government of Uganda: National Development Plan

2010/2011 – 2014/2015

2. UNICEF (2010) Raising Clean Hands, Advancing

Learning, Health and Participation Through WASH in

Schools. Joint Call to Action 2010. Contributed to

by CARE, Dubai Cares, Emory University Center for

Global Safe Water, IRC International Water and

Sanitation Centre, Save the Children, UNICEF, Water

Advocate, Water AID, Water for People, WHO.

xxxv

3. Figure 3.1: Trends in number of cases registered in Public health facilities

from January - December 2011

Figure 3.2: Trends in number of cases registered in Public health facilities from

December 2011 – November 2012

xxxvi

Table 3.4: Distribution of respondents from the six schools

School Name Class of pupil Total

Freq(%age)P. 4 P 5 P 6

Good Times Infant P/S 16(6.2%) 13(5.0%) 14(5.4%) 43(16.6%)

Kawempe Mbogo Muslim

P/S

8(3.1%) 17(6.6%) 24(9.3%) 49(18.9%)

Uganda Martyrs P/S 14(5.4%) 13(5.0%) 22(8.5%) 49(18.9%)

St. Charles Lwanga P/S 15(5.8%) 7(2.7%) 10(3.9%) 32(12.4%)

St. Martin Mulago 12(4.6%) 11(4.2%) 25(9.7%) 48(18.5%)

Kawempe COU P/S 10(3.9%) 13(5.0%) 15(5.8%) 38(14.7%)

Total 75(29.0%

)

74(28.6%

)

110(42.5%) 259(100.0%)

Table 3.22: Pupils using what they learnt about Hygiene and

Sanitation

Pupil using what they learnt

at school

Total

Name of the school Yes NoGood Times Infant P/S 33(100.0%) 0(0.0%) 33(100.0%)Kawempe Mbogo Muslim

P/S

48(100.0%) 0(0.0%) 48(100.0%)

Uganda Martyrs P/S 46(97.9%) 1(2.1%) 47(100.0%)St. Charles Lwanga P/S 32(100.0%) 0(0.0%) 32(100.0%)St. Martin Mulago P/S 46(97.9%) 1(2.1%) 47(100.0%)Kawempe CoU P/S 35(97.2%) 1(2.8%) 36(100.0%)Total 240(98.8%) 3(1.2%) 243(100.0%)

xxxvii

Table 3.7: Sources of drinking water in different schools

Source of

drinking

water

Name of school TotalGood

Times

Infant

P/S

Kawempe

Mbogo

Muslim

P/S

Uganda

Martyrs

P/S

St.

Charles

Lwanga

P/S

St.

Martin

Mulago

P/S

Kawempe

COU P/S

Rain water

tank

3(7.0%) 0(0.0%) 9(23.7%

)

0(0.0%) 2(4.9%) 0(0.0%) 14(6.2%)

Carry from

home

0(0.0%) 0(0.0%) 1(2.6%) 0(0.0%) 3(7.3%) 3(12.5%

)

7(3.1%)

Tap 0(0.0%) 0(0.0%) 1(2.6%) 0(0.0%) 2(4.9%) 2(8.3%) 5(2.2%)Well 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%) 4(16.7%

)

4(1.8%)

Solvatten 39(90.7

%)

49100%) 25(65.8

%)

3(9.7%) 11(26.8

%)

0(0.0%) 127(56.2

%)Teacher 0(0.0%) 0(0.0%) 2(5.3%) 1(3.2%) 10(24.4

%)

12(50.0

%)

25(11.1%

)Others(buy) 0(0.0%) 0(0.0%) 0(0.0%) 27(87.1

%)

12(29.3

%)

3(12.5%

)

42(18.6%

)Total 43(100% 49(100% 38(100% 31(100% 41(100% 24(100% 226(100%

xxxviii

) ) ) ) ) ) )

Table 3.8: Boiling drinking water at home

Name of school Boiling drinking water TotalBoil Do not boil

Good Times Infant P/S 42(97.7%) 1(2.3%) 43(100.0%)Kawempe Mbogo Muslim P/S 48(98.0%) 1(2.0%) 49(100.0%)Uganda Martyrs P/S 49(100.0%) 0(0.0%) 49(100.0%)St. Charles Lwanga P/S 31(96.9%) 1(3.1%) 32(100.0%)St. Martin Mulago 47(97.9%) 1(2.1%) 48(100.0%)Kawempe COU P/S 35(94.6%) 2(5.4%) 37(100.0%)Total 252(97.7%) 6(2.3%) 258(100.0%)

Table 3.9: Drinking water storage facilities at home

Name of school Drinking water storage facility Total Pot Jerry

can

Bucke

t

Plasti

c

Bottle

Jug Others

4(9.3%) 34(79.1%

)

0(0.0

%)

0(0.0%

)

5(11.6

%)

0(0.0%

)

43(100%

)Kawempe Mbogo

Muslim P/S

8(16.3%

)

40(81.6%

)

1(2.0

%)

0(0.0%

)

0(0.0%

)

0(0.0%

)

49(100%

)Uganda Martyrs

P/S

14(28.6

%)

33(67.3%

)

0(0.0

%)

0(0.0%

)

1(2.0%

)

1(2.0%

)

49(100%

)St. Charles

Lwanga P/S

12(37.5

%)

20(62.5%

)

0(0.0

%)

0(0.0%

)

0(0.0%

)

0(0.0%

)

32(100%

)

xxxix

St. Martin

Mulago P/S

4(8.3%) 38(79.2%

)

4(8.3

%)

1(2.1%

)

1(2.1%

)

0(0.0%

)

48(100%

)Kawempe COU P/S 27(75.0

%)

8(22.2%) 1(2.8

%)

0(0.0%

)

0(0.0%

)

0(0.0%

)

36(100%

)Total 69(26.8

%)

173(67.3

%)

6(2.3

%)

1(0.4%

)

7(2.7%

)

1(0.4%

)

257(100

%)

Table 3.10: Presence of covers on drinking water storage facilities

Drinking

water

storage

facility

Water container having

cover

Total

Had cover No cover

Pot 63(98.4%) 1(1.6%) 64(100.0%)Jerry can 163(94.2%) 10(5.8%) 173(100.0%)Bucket 6(100.0%) 0(0.0%) 6(100.0%)Plastic

Bottle

1(100.0%) 0(0.0%) 1(100.0%)

Jug 7(100.0%) 0(0.0%) 7(100.0%)Others 1(100.0%) 0(0.0%) 1(100.0%)Total 241(95.6%) 11(4.4%) 252(100.0%)

Figure 3.5: Sources of water for households use (bathing and

cleaning)

xl

Table 3.11: Observations of the sanitary facilities in the six schools Primary School Type of

latrine

Number of

stances

Comments

Boys GirlsUganda Martyrs P/S Ventilate

d

Improved

Pit

Latrine

8 7 The sanitary facilities were

clean

Hand washing facilities were

available containing water

mixed with liquid soapSt. Charles Lwanga

P/S

Ordinary

Pit

Latrine

4 4 Latrines were clean and dry,

toilet paper was available,

hand washing facility was

stationed near the latrineGood Times Infant

P/S

Ventilate

d

Improved

Pit

Latrine

2 4 Wet with urine, there was hand

washing facility near the

latrine containing water mixed

with liquid soap for hand

washing St. Martin Mulago

P/S

Ventilate

d

Improved

Pit

6 9 Latrines were clean but

smelling, empty hand washing

facility was available, the

latrines are extremely smelly

xli

LatrineKawempe COU P/S Ventilate

d

Improved

Pit

Latrine

6 7 Both boys and girls latrine

blocks were smelly with minimal

soiling

Construction of new latrines

was underwayKawempe Mbogo Muslim

P/S

Ventilate

d

Improved

Pit

Latrine

8 8 Latrine generally in better

state than at baseline.

Table 3.12: Pupil stance ratio in the six Schools Primary

School

Type of

latrine

Number of

stances

Enrolment 2012 Stance ratio Change

Boys Girl

s

Boys Girl

s

Tota

l

Boys Girl

s

Tota

l

(End

line

)

Tota

l

(Bas

elin

e)

Uganda

Martyrs

P/S

Ventila

ted

Improve

d Pit

Latrine

8 7 343 387 730 42.9 55.

3

48.7 +8.

6

+50.3

St.

Charles

Lwanga

P/S

ordinar

y Pit

Latrine

4 4 90 210 300 22.5 52.5 37.5 -2.3 +1.3

Good

Times

Ventila

ted

2 4 188 207 395 94 51.8 65.8 +25.

7

+34.3

xlii

Infant

P/S

Improve

d Pit

LatrineSt.

Martin

Mulago

P/S

Ventila

ted

Improve

d Pit

Latrine

6 9 471 545 1016 78.5 60.5 67.7 +27.

7

+27.2

Kawempe

COU P/S

Ventila

ted

Improve

d Pit

Latrine

6 7 380 320 700 63.3 45.7 53.8 +13.

8

+18.2

Kawempe

Mbogo

Muslim

P/S

Ventila

ted

Improve

d Pit

Latrine

8 8 328 299 627 41 37.4 39.2 -0.8 +3.8

xliii