Global Leadership Training Programme in Africa 2014
RESEARCH REPORT

Impact of Hygiene Practices at Early Childhood Development Centers on
Hygiene Practices and Health Outcomes of ECD Children in Rural Communities,
Kenya
Kanako Takeshita1

Abstract
Lack of improved hygiene environment is one of the main risk factors of diarrhea andpneumonia among children aged under five in the world. These diseases are leading causes of deathamong them. In Kenya, located in the sub-Saharan Africa region, the health of ECD children isneglected. Diarrhea and pneumonia account for approximately one-third of under-five deaths.
Changing hygiene practices and environment have been regarded as keys to protecting children’s
health. The objectives of this study are threefold. First, this study will examine whether the training
on hygiene practices for ECD teachers is effective in improving hygiene practices and health outcomesof ECD children. Second, it will examine the association between hygiene practices and healthoutcomes of ECD children. Third, it will examine the factors associated with hygiene practices of ECD
teachers, hygiene practices and health outcomes of ECD children.

要旨
安全な飲料水及び基本的な衛生施設へのアクセスの欠如は、5 歳未満児における下痢症や呼吸器疾患などをもたらすリスク要因の一つであり、これらの感染症は 5 歳未満児における主な死亡要因である。サブサハラアフリカ地域に属するケニア共和国では、5 歳未満児の死亡要因の約 3 分の 1 が下痢症及び急性呼吸器疾患によるものである。学術的には、衛生環境を改善し、衛生に関する行動を変えることで、子どもの健康を守ることができることが知られている。本研究の目的は、幼稚園における衛生改善が、児童の衛生行動及び健康状態に与える影響及びその要因を明らかにすることである。

1

Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 2 nd yearof Master Course/ Kenyatta University, February to May 2015.

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1. Introduction
Lack of improved hygiene environment is severe public health issues among the marginalized
and vulnerable population. In 1990, only 49% of the world population had access to improved
sanitation facilities and 76% had access to improved water sources in the world, but it increased to
64% and 89% in 2012. The pace of these progresses, however, was slow in Oceania and subSaharan African regions for sanitation facilities and Central Asia region for water sources. (1, 2)
Globally, rural population contributes approximately 90% of population for the lack of access toimproved drinking water sources. Likewise, it accounts for 70% of population for the lack access tosanitation facilities. (2) Lack of improved hygiene environment is one of the main risk factors ofdiarrhea and pneumonia among children aged under five. These diseases are leading causes of deathamong them. (3, 4)Hygiene promotion has been identified as an effective approach to prevent diseases throughchanging poor hygiene behavior. (5, 6) It is a planned approach based on the existing local healthproblems, motivation for hygiene and appropriate channel of communication of the targeted groups.
Changing hygiene practices and environment have been regarded as keys to protecting children’s
health too. (4, 7) Globally recommended hygiene practices include handwashing (washing hands
before eating and after toilet with soap), water management and treatment, and the correct use of
latrines.(8) These hygiene practices prevent children from receiving infectious diseases such as
diarrhea and pneumonia. (8, 9)Hygiene promotion has been known to be effective on children’s health at the household level
and the primary school level. Learning on child health through neighborhood meetings andparticipatory women’s group is effective to improve knowledge and hygiene practices of mothers. (10,11) It reduced 12.2% incidence of acute respiratory infections among their children aged under five.
(10) At the primary school level, hygiene promotion also improved knowledge and hygiene practicesof children. It reduced 35% absenteeism among students of grades 4 to8, too. (12)ECD center typically covers children aged three to six, one of the riskiest groups of diarrhea
andpneumonia. An ECD center can be a channel of spreading diarrhea and pneumonia amongchildren from different households. Limited knowledge is available whether hygiene promotion in ECD
centers can change hygiene practices and improve health status of ECD children.
In Kenya, located in the sub-Saharan Africa region, the health of ECD children is neglected.
(13) Diarrhea and pneumonia account for approximately one-third of under-five deaths in Kenya. (14)Hygiene practices have been extensively promoted in communities and primary schools in rural Kenya.
2(12) However, ECD centers have not been considered as the target of these promotions. It may be
because parents and communities leaders recognize the role of ECD centers in educating child rather
than in protecting child health. (15, 16) More understanding is needed on the effectiveness of hygiene
promotion in ECD centers to protect the health of children aged under five.
The objectives of this study are threefold. First, this study will examine whether the training on
hygiene practices for ECD teachers is effective in improving hygiene practices and health outcomes of
ECD children. Second, it will examine the association between hygiene practices and health outcomesof ECD children. Third, it will examine the factors associated with hygiene practices of ECD teachers,
hygiene practices and health outcomes of ECD children.

2. Methods
2.1. Study design and study area
This study is a cross-sectional comparative study between Migwani and Masinga Districts
located in the eastern part of Kenya. Migwani and Masinga Districts are semi-arid area. The major
ethnic group in this area is Kamba. In the study area, Community Action Development Organization(CanDo), an international NGO for community development, run an ECD project. As an intervention,
the project purposively selected 9 out of 94 public ECD centers in Migwani District for the training of
hygiene practices. The training was held in 2011 and 2012 for ECD teachers in the selected ECD
centers. ECD teachers received follow-up activities, including training for head teachers, caregivers,and ECD teachers about water, sanitation and hygiene in 2013 and 2014. During the training,teachers acquired essential health knowledge and hygiene practices at ECD centers.
2.2. ParticipantsParticipants were ECD teachers and ECD children who attended the selected ECD centers on
the day of data collection. ECD children aged two to seven years old. As an intervention group, thisstudy selected 8 out of 9 public ECD centers which received the intervention in Migwani District. The
participants were 12 ECD teachers who attended the training of hygiene practices and follow-up
activities and 225 out of 296 ECD children. Out of 225 ECD children, 196 have consent from theircaregivers to participate in this study. As a comparison group, this study selected 7 public ECD centerswhich did not receive intervention from any organization out of 120 in Masinga District. The
participants were 9 ECD teachers and 300 out of 306 ECD children. Out of 300 ECD children, 296
have consent from their caregivers to participate in this study.
2.3. Measurements
3Semi-structured questionnaire was developed in English. This questionnaire was pre-tested
among 25 ECD teachers of public ECD centers in Masinga District prior to the main data collection.
Then, the questionnaire was modified for the main study.
Variables of this study are hygiene practices of ECD teachers and children, the characteristics of ECD
center, teachers and children, health knowledge of ECD teachers and absenteeism of ECD children.
2.3.1. Independent variables
Independent variables of this research are hygiene practices of ECD teachers and children, thecharacteristics of ECD center, teachers and children, health knowledge of ECD teachers.
2.3.1.1. Hygiene practices of ECD children
Hygiene practices of ECD children were measured by observation with checklist. Hygiene
practices of ECD children include handwashing at proper time (before having meals, after visiting thelatrines and after playing), handwashing with proper materials (with only a water, a soap and water,
ash and water), drying hands after washing, sitting during the meals.
2.3.1.2. Hygiene Practices that ECD Teachers Implement at ECD Centers
Hygiene practices of ECD teachers were measured by face-to-face interviews using semistructured questionnaire and observation. Hygiene practices of ECD teachers include personal hygiene
at ECD centers, water management and treatment, cleaning latrines and classroom, washing utensils
for feeding (dishes and cups of children), making and using dish rack and water container,
encouraging hygiene practices of ECD children. ECD teachers learned these hygiene practices during
the training.
2.3.1.3. The characteristics of ECD centers, teachers, and children
The characteristics of ECD centers were measured by face-to-face interviews with ECD
teachers using semi-structured questionnaire. The characteristics of ECD centers include water
sources, water storage, the facilities of toilets, and the number of ECD teachers and children. The
characteristics of ECD teachers include age, gender, socioeconomic status, academic status, and thehistory of receiving training. The characteristics of ECD children include age and gender
2.3.1.4. Health Knowledge of ECD Teachers
Health knowledge of ECD teachers was measured by using semi-structured questionnaire.
Health knowledge include about water-related diseases, the method to prevent these diseases, the4

way of water management and treatment, the method of making dish rack and water container,
about child-friendly latrine. ECD teachers learned such knowledge in the training.
2.3.2. Dependent variables
2.3.2.1. Child absenteeism
Disease-related child absenteeism in the past 2 weeks were collected from face-to-faceinterviews with ECD teachers using their records.
2.3.2.2. Illnesses and health problems of ECD children
Illnesses and health problems which ECD children had in the past 2 weeks were collected fromface-to-face interviews with ECD teachers.
2.4. Data collection
Data were collected through face-to-face interview with semi-structured questionnaire to ECD
teachers and observation of ECD teachers and children from March to May, 2015. Local staffs of
CanDo served as research assistants. Hygiene practices of ECD teachers and children were observed
during a school day. ECD children wear a shirt with an ID number so that researchers can identify
whether each child exercises hygiene practices. Face-to-face interviews with ECD teachers were also
conducted at each ECD center after school. Researcher and research assistants will also conduct anobservation survey at each ECD center during the school time.

2.5. Data analysis
All collected data were coded and entered into STATA version 13. Differences in thecharacteristics of ECD teachers and children among the intervention and control groups were
examined using chi-squared test of independence and analysis of variance. Collected data will beanalyzed from questionnaire and observation by the multilevel linear and logistic regression models
with a random intercept at the school level.

3. Research findings
Research results will be obtained after the data analysis. As an initial research findings,
hygiene practices such as handwashing and eating attitude were well encouraged to ECD children by
ECD teachers in comparison group more than in intervention group according to the observation at
5ECD

centers. It is opposite finding from the hypothesis of this research. The kinds of hygiene

practices of ECD teachers and children were differ from one ECD center to another. Hygiene
environment such as water resources and toilets of ECD centers were also vary among ECD centers.
According to the questionnaire survey, the kinds of illnesses and health problems of ECD
children in intervention group and comparison group were similar. There were diarrhea, malaria,
ringworm, scabies, tapeworm, typhoid, malnutrition, fever, cough and running nose. Diarrhea, malaria,
ringworm, scabies, typhoid and malnutrition are water-related diseases. Some ECD teachers could not
answer health problems of their ECD children, because they do not pay attention to health status ofthem.

4. Discussion and conclusion
It is need to examine the factors associated with hygiene practices of ECD teachers andchildren to explain why hygiene practices of ECD teachers and children were observed more incomparison group than in intervention group. According to the observation, the characteristics of ECD
centers, teachers and children will be factors associated with hygiene practices of ECD teachers.
Additionally, the motivation of ECD teachers and social relationship between ECD teachers, headteacher of the school and parents of ECD children is considered to be one of the associated factors
with hygiene practices of ECD teachers to examine. Hygiene practices of ECD teachers will be one of
the important factors associated with hygiene practices of ECD children. It is also need to examine
which independent variables are affected to the health outcomes of ECD children.
Also, it is need to consider that management system of educational services is different
between Migwani and Masinga Districts due to the decentralization which have started in Kenya since2013. Migwani District belongs to Kitui County and Masinga District belongs to Masinga County. The
salary payer for ECD teachers is different among them. The payers are county in Kitui County andparents in Masinga County. It make a difference in the amount of salary for ECD teachers. It isaffected the characteristics of ECD teachers of this research.

5. Ethical consideration
This study obtained approval from the Research Ethics Committee of the University of Tokyo.
We also requested for ethical approval from the National Commission for Science, Technology andInnovation, Kenya. This study was designed and conducted in collaboration with the Kenyatta
University in Kenya under the program organized by the United Nations University. We conducted this6

study in cooperation with CanDo. Before one week of the data collection, the Area Educational Officer
distributed a letter to selected ECD teachers and head teachers of each primary school which ECD
centers attributed from, and parents/caregivers of ECD children. Researcher and research assistants
explained to them the objectives of this study and obtained the consent form. During the datacollection, the participants have an opportunity to refuse or to discontinue the participation at any
time. The confidentiality will be ensured by removing all personal identifiers from the collected data.

6. Reflection on the Global Leadership Training Program in Africa
The Global Leadership Training Program in Africa was a great opportunity for me and thisresearch because I could discuss with professors in different areas from public health. We discussed
about my research based on their culture, policy and their cumulative academic knowledge. For
example, Dr. Mangriu and Dr. Muriuki in Environmental Education studies helped me to modify thequestionnaire based on their culture. I also had an opportunity to discuss about the research needs
with Dr. Rachel in Educational studies. First, there are limited studies which specifically examine
hygiene behavior at early childhood development centers in Kenya. Second, this study will contributeto the strategy of government in reducing child mortality. The First Lady is conducting the “Beyond
Zero Campaign” which is one of the initiatives of strategic framework towards HIV control, promotionof maternal, new born and child health in Kenya since 2014. I would like to show my gratitude to all
professors who helped me to improve my research.

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Acknowledgement
This study is supported by the Global Leadership Program in Africa of United Nations
University –Institute for the Advanced Study for Sustainability. The author thank Dr. Mangriu, Dr.
Muriuki, and Dr. Rachel in Kenyatta University. The support of International NGO, Community Action
and Development Organisation (CanDo) is highly appreciated.

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