Impact of a hygiene curriculum and the installation of simple handwashing and drinking water stations in rural Kenyan primary schools on student health and hygiene practices.

School-based hygiene and water treatment programs increase student knowledge, improve hygiene, and decrease absenteeism, however health impact studies of these programs are lacking. We collected baseline information from students in 42 schools in Kenya. We then instituted a curriculum on safe water and hand hygiene and installed water stations in half ("intervention schools"). One year later, we implemented the intervention in remaining schools. Through biweekly student household visits and two annual surveys, we compared the effect of the intervention on hygiene practices and reported student illness. We saw improvement in proper handwashing techniques after the school program was introduced. We observed a decrease in the median percentage of students with acute respiratory illness among those exposed to the program; no decrease in acute diarrhea was seen. Students in this school program exhibited sustained improvement in hygiene knowledge and a decreased risk of respiratory infections after the intervention.

Anal cleansing practices and faecal contamination: a preliminary investigation of behaviours and conditions in schools in rural Nyanza Province, Kenya.

OBJECTIVE: To learn how children in rural schools in Nyando District, Kenya clean themselves after defecation. METHODS: Six focus group discussions were held with boys and girls ages 12-15 in three rural schools in mid-2009. Parents were interviewed in one setting. In early 2010, a survey of head teachers was conducted in 114 schools in Nyanza Province, Kenya, to assess the provision of anal cleansing materials and handwashing water and soap in schools. RESULTS: Anal cleansing behaviour is linked with access to materials, age, social pressure, perceived personal risk of illness and emotional factors. Materials used for anal cleansing include schoolbook paper, leaves, grasses, stones, corncobs and one's own hands. Students have knowledge gaps in terms of personal hygiene. They were forthcoming with information on their anal cleansing practices. Almost no schools budgeted for or provided anal cleansing materials regularly. CONCLUSION: Anal cleansing is a necessary human activity. However, because of social taboos, there are few articles on the topic. School health plans overlook it as well. Researchers need to determine if and how current practices could harm child health to inform policy.

'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya.

BACKGROUND: The onset of menstruation is a landmark event in the life of a young woman. Yet the complications and challenges that can accompany such an event have been understudied, specifically in resource-poor settings. As interventions aim to improve female attendance in schools, it is important to explore how menstruation is perceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls' perceptions and practices related to menstruation METHODS: Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus group discussions, in-depth interviews, and field notes from observations, researchers collected information from 48 primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes, followed by manual coding of the narratives. RESULTS: Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct one another on management practices and advise one another on coping mechanisms. Girls expressed fear, shame, distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense of embarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception that the onset of menstruation signals the advent of a girl's sexual status. Among the many methods for managing their periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts or dresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing, which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls toward menstruation have been arranged into personal, environmental and behavioural factors. CONCLUSION: Further research on menstrual management options that are practical, sustainable and culturally acceptable must be conducted to inform future programs and policies that aim to empower young girls as they transition into womanhood. Stakeholders working within this and similar contexts must consider systematic mechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies or guiding girls on how to create supplies serve as critical components for future interventions.

Enhancing a safe water intervention with student-created visual aids to promote handwashing behavior in Kenyan primary schools.

The Nyando Integrated Child Health Education (NICHE) project was a collaborative effort by the U.S. Centers for Disease Control and local partners to assess the effectiveness of multiple interventions for improving child survival in western Kenya. To increase handwashing in schools, NICHE trained teachers and installed handwashing stations with treated water and soap in 51 primary schools. This cluster-randomized trial evaluated an additional educational strategy (a poster contest themed, "Handwashing with Soap") to improve handwashing behavior in 23 NICHE primary schools. Pupils were engaged in the poster development. Pupil handwashing behavior was observed unobtrusively at baseline and after four months. Intervention schools displayed a significant increase in the number of handwashing stations and proportion of teacher-supervised stations over the study period. No significant between-group differences of intervention in handwashing frequency, soap availability, or visibility of handwashing stations was observed. Despite finding a limited effect beyond the NICHE intervention, the trial appeared to promote sustainability across some measures.

Monitoring the marketing, distribution, and use of Sprinkles micronutrient powders in rural western Kenya.

BACKGROUND: In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products. OBJECTIVE: To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors. METHODS: Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews. RESULTS: A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 sachets were sold wholesale to vendors, with variability in sales influenced by the social, political, and economic context. Vendors living closer to the wholesale office purchased more Sprinkles, so a second office was opened closer to remote vendors. On average, 33% of households purchased Sprinkles during household monitoring visits. Training sessions and community launches were important for community support and raising awareness about Sprinkles. Vendor incentives motivated vendors to sell Sprinkles, and consumer incentives promoted purchases. CONCLUSIONS: Sprinkles program monitoring in Kenya was critically important for understanding sales and distribution trends and vendor perceptions. Understanding these trends led to strategic changes to the intervention over time.

Formative research exploring acceptability, utilization, and promotion in order to develop a micronutrient powder (Sprinkles) intervention among Luo families in western Kenya.

BACKGROUND: There is a lack of peer-reviewed literature describing in detail the formative research to develop Sprinkles interventions. OBJECTIVE: To describe community members' reactions to and experiences using Sprinkles, with an emphasis on acceptability, utilization, and promotion. METHODS: Fourteen initial focus group discussions on Sprinkles and a 25-family home study were conducted. For the home study, each child 6 to 59 months of age in the household received 30 sachets (1 per day). The initial 14 focus group discussions included mothers, grandmothers, vendors, women who purchased from vendors, and adults in the general population. Home study families were recruited from participants in the initial 14 focus group discussions who had at least one child 6 to 59 months of age. RESULTS: Sprinkles were highly acceptable to adults and most children; some children thought Sprinkles were sugar. Most home study families prepared and used Sprinkles correctly. All families reported positive effects, particularly increased appetite, and recommended Sprinkles; none experienced major problems. Potential barriers identified were lack of knowledge of and experience with Sprinkles, availability of Sprinkles, and cost. Promotional messages targeted to mothers, fathers, all child-care providers, and doctors focused on the positive health effects of Sprinkles. CONCLUSIONS: Issues related to Sprinkles preparation, use, and barriers required attention before implementation. Locally appropriate visual and written instructions were developed for dissemination. Intervention training sessions and promotions were tailored to answer frequently asked questions, increase knowledge of Sprinkles, and provide tangible evidence of health benefits. Information needs and perceptions changed quickly after use of Sprinkles. Existing levels of Sprinkles awareness and knowledge should be considered when designing interventions.

Association of attitudes and beliefs towards antiretroviral therapy with HIV-seroprevalence in the general population of Kisumu, Kenya.

BACKGROUND: Since antiretroviral therapy (ART) became available in the developed world, the prevalence of unprotected sex and the incidence of sexually transmitted infections (STIs) and HIV have increased. We hypothesized that a similar phenomenon may be occurring in sub-Saharan Africa concomitant with the scale-up of HIV treatment. METHODS: We conducted a general population-based survey in Kisumu, Kenya. Participants completed an interview that included demographics as well as ART-related attitudes and beliefs (AB) and then underwent HIV serological testing. Exploratory and confirmatory factor analyses of AB about ART indicated two factors: 1) ART-related risk compensation (increased sexual risk taking now that ART is available); and 2) a perception that HIV is more controllable now that ART is available. Logistic regression was used to determine associations of these factors with HIV-seroprevalence after controlling for age. FINDINGS: 1,655 (90%) of 1,844 people aged 15-49 contacted, including 749 men and 906 women, consented to participate in the study. Most participants (n = 1164; 71%) had heard of ART. Of those who had heard of ART, 23% believed ART was a cure for HIV. ART-related risk compensation (Adjusted (A)OR = 1.45, 95% CI 1.16-1.81), and a belief that ART cures HIV (AOR = 2.14, 95% CI 1.22-3.76) were associated with an increased HIV seroprevalence in men but not women after controlling for age. In particular, ART-related risk compensation was associated with an increased HIV-seroprevalence in young (aged 15-24 years) men (OR = 1.56; 95% CI 1.12-2.19). CONCLUSIONS: ART-related risk compensation and a belief that ART cures HIV were associated with an increased HIV seroprevalence among men but not women. HIV prevention programs in sub-Saharan Africa that target the general population should include educational messages about ART and address the changing beliefs about HIV in the era of greater ART availability.