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

Overview

Project Description

Rationale

Aims & objectives

Methodology

Study site

Key Findings/Results

Comparison of dry and rainy seasons

Potential Intervention Approaches

Questions & Discussion

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

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

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 stools; general water use; personal hygiene behaviors: face/handwashing, wiping of face or ocular or nasal secretions and

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

Thematic Analysis

Study Site: Wera Jarso, Oromia

Rural, pastoralist, low literacy

60.26% rural pop. using unimproved water

source

96.83% rural pop. no bathing facility

Study Site: Trachoma

Prevalence

Trachoma Atlas: Ethiopia Country Profile

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

Typical Compounds

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

Sanitation

Above: Young child

open defecating in

immediate compound,

adjacent to living

structure

Below/Right:

Examples of

poorly

constructed HH

latrines

Sanitation Comparison

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.]”

Water Collection

Left to right: Typical water point; Child ‘playing’ with water; Rainwater collection/storage

container

Water Point Collection

Comparison

0

20

40

60

80

100

120

HH1 HH2 HH3 HH4 HH5 HH6 HH7 HH8 HH9 HH10

Lite

rs o

f w

ater

co

llect

ed/d

ay

Households

Dry Season Rainy Season

Water Comparison

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)

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

Typical Washing Routine

Hands

Arms Face

Hygiene Comparison

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

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

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

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

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

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

Questions and Discussion

Thank You!

Amesegenalehu!

Contact Information:

Katina Sommers MSc Candidate,

LSHTM

Katina.Sommers@gmail.com

QUESTIONS &

DISCUSSION