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Sanitation and hygiene in urban andrural households in East AfricaJames Tumwine a , John Thompson b , Munguti Katui-Katua c ,Mark Mujwahuzi d , Nick Johnstone e & Ina Porras ba Department of Paediatrics and Child Health , MakerereUniversity Medical School , PO Box 7072, Kampala, Ugandab International Institute of Environment and Development (IIED) ,3 Endsleigh St, London, WC1H ODD, UKc Community Management and Training Services (East Africa) ,National Bank Building, Ongata Rongai, Magadi Road PO Box 292Kiserian, Nairobi, Kenyad Institute of Resource Assessment , University of Dar es Salaam ,PO Box 49039, Dar es Salaam, Tanzaniae National Policies Division Environment Directorate ,Organisation for Economic Cooperation and Development , 2 rueAndré Pascal, Paris, 75016, FrancePublished online: 21 Jul 2010.

To cite this article: James Tumwine , John Thompson , Munguti Katui-Katua , Mark Mujwahuzi ,Nick Johnstone & Ina Porras (2003) Sanitation and hygiene in urban and rural households inEast Africa, International Journal of Environmental Health Research, 13:2, 107-115, DOI:10.1080/0960312031000098035

To link to this article: http://dx.doi.org/10.1080/0960312031000098035

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Sanitation and hygiene in urban and ruralhouseholds in East Africa

JAMES K. TUMWINE1, JOHN THOMPSON2, MUNGUTI KATUI-KATUA3,

MARK MUJWAHUZI4, NICK JOHNSTONE5 and INA PORRAS2

1Department of Paediatrics and Child Health, Makerere University Medical School, PO Box 7072, Kampala, Uganda,2International Institute of Environment and Development (IIED), 3 Endsleigh St., London, WC1H ODD, UK,3Community Management and Training Services (East Africa), National Bank Building, Ongata, Rongai, Magadi

Road, PO Box 292, Kiserian, Nairobi, Kenya, 4Institute of Resource Assessment, University of Dar es Salaam, PO Box

49039, Dar es Salaam, Tanzania, 5National Policies Division, Environment Directorate, Organisation for Economic

Cooperation and Development, 2 rue Andre Pascal, Paris 75016, France

Latrine possession, disposal of children’s faeces and waste-water in 1015 households in 33 sites in Kenya,

Tanzania and Uganda were studied in 1997. Assistants conducted interviews and observed the state and

use of latrines, disposal of children’s faeces, wastewater, and household socio-demographic characteristics.

Latrine possession was 92.4% in Uganda, 95% in Kenya and 99.5% in Tanzania. In unpiped sites, 73.5%

of Ugandan, 90.5% of Tanzanian and 95% of Kenyan households had latrines. Over 30% of latrines in

rural Uganda were contaminated with faeces, compared with 10% in Tanzania. More latrines in urban

Kenya and Uganda had contaminated surroundings than in the rural areas. The mean number of people

using a toilet in the urban areas (10) was significantly higher than in rural areas (7), (F=45.5; P5 0.001).

Toilets in Kenya and Uganda were more likely to be fouled than in Tanzania. Households where the head

was an educated professional or business person, or the toilet had a door, lid or concrete wall or floor or

waste water was disposed of in the latrine, were less likely to have fouled toilets. Most households disposed

of the faeces safely with a few placing them in the garden or elsewhere. The study emphasises the need to

promote appropriate sanitation and hygiene.

Keywords: sanitation; hygiene; East Africa; urban; rural.

Introduction

While there has been a lot of emphasis on water and sanitation improvements to reduce the

transmission of diarrhoea and other diseases, there is a dearth of information on sanitation and

hygiene practices in East Africa.

In a review of over 60 studies, Esrey et al. (1985) found that the largest benefits of service

improvements in reducing morbidity-related diarrhoea were improved water availability (25%),

improved excreta disposal (22%), and water quality (16%). There is controversy, however,

regarding the relative role of water and sanitation improvements in reducing diarrhoea

morbidity. In a cross-sectional analysis involving eight countries (including Uganda), Esrey

(1996) found that sanitation improvements conferred much larger benefits than water

improvement, while Wibowo and Tisdell (1993) from Indonesia, provided additional evidence

Correspondence: James K. Tumwine, Department of Paediatrics and Child Health, Makerere

University Medical School, PO Box 7072, Kampala, Uganda. Tel: 256-41-531875; 256-77-494120;

Fax: 256-41-345597; E-mail: jtumwine@imul.com

International Journal of

Environmental Health Research 13, 107 – 115 (June 2003)

ISSN 0960-3123 printed/ISSN 1369-1619 online/03/020107-09 # 2003 Taylor & Francis Ltd

DOI: 10.1080/0960312031000098035

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of the efficacy of water and sanitation in improving health status. Despite disagreement over the

possible impact of provision of water and sanitation services (Esrey 1996; Cairncross et al.

1997), it seems that provision of optimal water and sanitation services will result in greater

benefit than just focusing on one or the other.

Access to sanitation is generally defined as ‘at least adequate excreta disposal facilities that

can effectively prevent human, animal and insect contact with excreta. Suitable facilities range

from simple but protected pit latrines to flush toilets with sewerage.’ (WHO 1996). Improving

hygiene practices in the home has received a lot of attention (Curtis et al. 2000). Clearly

practices which prevent stools getting into the home environment are likely to have a great

impact on health. For example disposal of children’s faeces safely might prove more important

than hand washing before eating or preparing food, while washing after handling child or

faeces is critical. Available evidence seems to suggest that sanitation is as effective in preventing

diseases as improved water supply (WHO/UNICEF 2000). However, in order to reap this

maximum benefit, household members must undergo major behavioural changes.

Possession of latrines in Africa seems to have increased over the years, but hard evidence is

very difficult to come by. Overall only 60% of the population in Africa is said to have adequate

sanitation coverage, ranging from 45% in the rural areas to 84% in the urban areas (WHO/

UNICEF 2000). A few site-specific studies have reported diverse findings. For example in the

Lesotho highlands, Kravitz et al. (1999) found that lack of sanitation was a serious problem

with less than 5% of villagers using latrines. The situation in Malawi (Grimason et al. 2000)

was better: 67% of the households in a high density urban township used traditional latrines

with earthen floors while only 20% used latrines with concrete floors known as sanitation

platforms (saniplats). Most squat-hole covers were fouled with faecal matter. Only 5% of the

households were using ventilated improved latrines while 8% used a neighbour’s latrine.

There is very little information about disposal of children’s faeces. In a study in Peru, Yeager

et al. (1999) found that the main defecation sites for young children were nappies, potties, and

the ground in or near the home, followed by latrines and flush toilets.

However, despite investments in sanitation programmes, the population with access to safe

sanitation in East Africa remains low (WHO/UNICEF 2000).

In recent years the historical emphasis on water and sanitation facility improvements to

reduce the transmission of diseases has shifted, with increased attention on the effects of

hygiene behaviour rather than service improvements per se (Kolsky 1993; Esrey 1996; Varley et

al. 1998). Personal hygiene promotion programmes tend to reduce transmission of water-

washed diseases (spread through inadequate personal hygiene) and possibly water-borne

transmission (spread through contaminated water supplies) as well. In view of the above, the

objectives of this study were to establish the status of latrine possession, hygiene, mode of

disposal of children’s faeces, and methods of waste water disposal in East Africa.

Materials and methods

Setting

The study was carried out in 1997 in the 33 East African sites studied in the original ‘Drawers of

Water’ (DOW 1) study (White et al. 1972). Selection of these sites by the DOW 1 study team

was ‘purposive’, employing the available field assistants who returned to their home areas to

carry out the study. In addition to returning to the original sites, similar research methods were

used in 1997, as had been the case for DOW 1 in 1972. The field assistants were university

graduates (DOW 1 used university undergraduate students) who spoke the local languages and

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were trained for 2 weeks. The training involved intensive workshops and fieldwork sessions and

provided an opportunity for the field assistants to familiarise themselves with the study’s

objectives and methodology. The details of the methodology are described elsewhere (White et

al. 1972; Tumwine et al. 2002).

Sampling issues and methodology

Sample households in unpiped sites were selected using a grid of 21 to 27 cells over an area of 8

square kilometres, using the same sampling method originally used by White et al. (1972). A

point within each cell was selected by using the co-ordinates of randomly selected numbers, and

the household nearest the point was chosen for interview. Piped sites were limited to the

original urban areas studied in DOW 1.

Sampling inpiped siteswas quite different. Selected households in the piped siteswere chosenby

systematic random sampling, taking every 10th house beginning at a number selected at random.

At each unpiped household, semi-structured interviews were conducted and observations

made. Data were collected on socio-demographic characteristics, state and use of latrines,

disposal of children’s faeces and wastewater disposal.

Statistical analysis

This was done using SPSS 8.0 (SPSS Chicago). Normally distributed continuous variables were

compared using the Student’s t-test. Categorical data were compared using the w2 test.Given the potential health implications of not having access to a sanitation facility, the

determinants of the likelihood of an individual household having access to a sanitation facility

were evaluated using multivariate logistic regression. The independent variables used in the

model were as follows: whether household had a piped water connection, country (Kenya/

Tanzania), location (rural or urban), cost of water, proportion of children in household,

number of people in household, education level of household head, occupation of household

head.

In addition to the above, the following variables were used in the model to identify the

determinants of faecal contamination inside the latrine and its surroundings: per capita water

used for cleaning, bathing; waste water disposed of in the open ground, sanitation facility is a

pit latrine, sanitation facility wall material permanent/temporary, latrine has door, latrine has

lid, latrine floor material permanent or temporary, number of people using latrine daily.

Results

One thousand and fifteen households were studied in 33 East African sites in Kenya, Tanzania

and Uganda. Sixty per cent of the households were urban and the rest were rural.

Possession of a sanitation facility

Latrine possession was almost universal in the piped sites and ranged from 92.4% of the

households in Uganda to 95% in Kenya and 99.5% in Tanzania. The sanitation situation in the

unpiped sites was surprisingly not very much different from that of the piped sites: 73.5% of

Ugandan, 90.5% of Tanzanian and 95% of Kenyan rural households had adequate sanitation

facilities. A similar observation was made for urban and rural households. Over 30% of the

latrines in the rural areas in Uganda were contaminated with faeces compared to only 10% in

Tanzania. Almost one in every five toilet facilities in the urban areas in Kenya and Uganda was

also contaminated by faecal matter, compared to only one in 10 in Tanzania (Fig. 1).

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In contrast to the pattern for internal contamination, which was more common in the rural

areas, the latrine surroundings were contaminated for more households in the urban areas of

Kenya and Uganda than in the rural areas, reflecting an unhygienic environment in the urban

sites studied (Fig. 2).

The pit latrine was the commonest type of sanitation facility in the unpiped sites in all three

countries while the flush toilet was the commonest type in the piped sites. However almost half

(48.2%) of the Kenyan and piped households used a pit latrine. Uganda (27.7%) and Tanzania

(20%) had fewer piped households using pit latrines (Fig. 3).

Most of the toilet superstructures in the urban areas were made from permanent material in

contrast to structures in the rural areas which were, more often, made with temporary materials

such as mud and wattle (Fig. 4). The means of disposal of wastewater (‘grey water’) in the

unpiped sites are shown in Fig. 5.

Most of the households in both urban and rural areas reported that they disposed of

children’s faeces in the latrine (Fig. 6).

The mean number of people using a sanitation facility in the urban areas (10) was

significantly higher than in rural areas (7), (F=45.5; P5 0.001).

Possible determinants of this fouling of the latrines was examined using multiple regression

analysis and it was found that households in Kenya (P=0.001) and Uganda (P=0.029)

were more likely to have fouled toilets than those in Tanzania. Multivariate regression

showed that households where the head was an educated professional (P=0.017) or business

person (P=0.013), or where the toilet had a lid (P=0.001) or concrete wall (P=0.013) or

where the waste water was disposed of in the latrine, (P=0.031) were less likely to have

fouled latrines.

The main determinant of faecal contamination of latrine surroundings was urban location

(P=0.001). However, the level of education of the household head (P=0.012), disposing of

Fig. 1. Proportion household latrines contaminated in urban and rural areas, east Africa, 1997.

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Fig. 2. Distribution of households by contamination of latrine surroundings in urban and ruralareas, east Africa, 1997.

Fig. 3. Distribution of households by sanitation facility in piped and unpiped sites, east Africa, 1997.

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Fig. 4. Distribution of households by type of latrine wall in urban and rural areas in east Africa,1997.

Fig. 5. Distribution of unpiped households by site of disposal of wastewater, east Africa, 1997.

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wastewater in the latrine (P=0.021), and latrine wall constructed with bricks (P=0.001), were

all associated with no fouling of the latrine surroundings.

Regression analysis showed that it is the small (P=0.008) rural (P=0.007) households with

less educated (P=0.001) farmers (P=0.004) that are most likely not to have a latrine.

Discussion

This study investigated latrine possession and hygiene, place of disposal of children’s faeces and

methods of wastewater disposal in 33 sites in Kenya, Tanzania and Uganda.

Latrine possession was almost universal in households with a piped water supply in the three

countries. However, a quarter and just over 10% and 5% of the unpiped households in

Uganda, Tanzania and Kenya respectively had no sanitation facilities. A similar situation was

observed for rural and urban households. These findings confirm recent estimates by the World

Health Organisation and UNICEF (WHO/UNICEF 2000). However they differ significantly

from findings in Malawi (Grimason et al. 2000) and Zimbabwe (Root 2001) where just over half

the households had a latrine. Information from one area in the Lesotho highlands (Kravitz et

al. 1999) showed a more serious situation with less than 5% of the households using latrines.

Access to sanitation facilities seems not to be a random process. Indeed regression analysis

showed that it is the small rural households with less educated farmers that are most likely not

to have a latrine. This information has important policy implications since health education

without improvement in socio-economic status may not be effective (Taha et al. 2000). While it

has been argued that improving both water supply and sanitation generates health benefits

(Rosen and Vincent 1999), there is mounting evidence to show that improving domestic hygiene

practices is potentially one of the most effective means of reducing the burden of sanitation

related diseases (Curtis et al. 2000).

Fig. 6. Distribution of households by place of disposing children’s faeces in rural and urbanhouseholds, east Africa, 1997.

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Despite adequate latrine coverage, 10 – 30% of households in the three countries were using

latrines fouled with faeces. The finding is similar to that of Grimason et al. (2000) who found

most latrines in a high-density township in Malawi were fouled with faecal matter. Possible

determinants of this fouling of the latrines were examined using multiple regression analysis

and it was found that households in Kenya and Uganda were more likely to have fouled toilets

than those in Tanzania. This could be due to the fact there is strict enforcement of hygiene

regulations in Tanzania with hefty fines for those flouting the law on latrine possession and

hygiene (Mujwahuzi 2000).

Multivariate regression analysis showed that households where the head was an educated

professional or business person, or where the toilet had a door, lid or concrete wall or floor, or

where the wastewater was disposed of in the latrine, were less likely to have fouled latrines. This

is in agreement with findings from Dhaka Bangladesh where Hadi (2000) found that

households involved in credit schemes were more likely to use safe latrines than those who were

not involved in such programmes.

Determinants of faecal contamination of latrine surroundings included urban location and

the number of people using the latrine. However, the level of education of the household head,

disposing of wastewater in the latrine, and latrine wall constructed with bricks, were all

associated with no fouling of the latrine surroundings. Most households in the three countries

disposed of the faeces in the latrine.

However, a small minority placed the faeces in the garden or elsewhere. Unfortunately this

issue was not explored in detail and should be looked at again in a future follow-up of the

households in the study sites.

This is important because there is now mounting evidence to show that improper disposal of

children’s faeces may be an important risk factor for diarrhoea in young children. In fact,

disposing of children’ s faeces in an unhygienic way might put household members at risk of

diarrhoea (Tumwine et al. 2002).

Conclusions

A number of conclusions arise from this study. More than three-quarters of the households

studied in the three countries possess sanitation facilities. The commonest sanitation facility in

the rural areas is the pit latrine while the flush toilet is the commonest in the urban areas.

Determinants of latrine possession include small rural households with less educated farmers.

Contaminated latrines are less likely to be found in households where the head is an educated

professional or business person, or where the toilet had a door, lid or concrete wall or floor, or

where the wastewater is disposed of in the latrine.

Despite substantial coverage, a sizeable number of households use fouled latrines with the

potential danger of infectious diseases. Therefore there is need to intensify the promotion of

appropriate sanitation and hygiene in this region.

Acknowledgements

Many thanks to the field assistants, and to Gilbert White, David Bradley, Sandy Cairncross,

Jan-Olof Dangert and Kathryn Jones for intellectual stimulation, and to John Baptist Lwanga,

Francis R Mugisha, Albert Maganda for assistance with data management and analysis.

Funded by generous support from DFID (UK), SIDA Sweden, DGIS, NEDA/Netherlands,

and the Rockefeller Foundation, USA.

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