Developing a Sustainable Point-Of-Use (POU) Water Treatment System to Reduce Diarrhea:

Assessing the Feasibility of Implementing a Hygiene

Behavior-Change Campaign in Africa’s Largest Urban Slum
Fenson-Hood, K.; Botta, R.; Caputo, L.; Scandurra, L.; Miniszewski, U.; Ringera, K.

The Kibera Slum

Study Location Methods Measurement

Theoretical Framework: The Kibera Slum • 15 focus groups
Theory of Reasoned Action & Planned Behavior Measured knowledge,
Nairobi, Kenya with 5-8 female practice, behavioral beliefs,
The theory is a framework that predicts participants per normative beliefs & control
Behavioral Attitudes
Beliefs
= Towards Behavior
how behavioral beliefs, normative beliefs, Kenya
group beliefs for diarrheal disease,
and control beliefs influence and
change behavior. • In-depth interview point-of-use (POU) water
follow-ups treatment & hand washing
• 1 case study with soap
Normative Behavioral New
= Intention
Beliefs Expectations Behavior

The theory predicts that if a person has a

positive attitude towards the behavior, high
Control expectations from others to perform the
= Self-Efficacy behavior, and high self-efficacy, then he/she
Beliefs
will have the intention to perform the
behavior. When there is intention, the
behavior will be adopted.

Point-of-Use (POU) Water Treatment & Hand Washing Behaviors

POU Water Treatment Hand Washing with Soap
Desired Behavior Desired Behavior
• Treat drinking water with WaterGuard chlorine & • Adults & children to wash hands with soap at
store drinking water in a safe storage container 5 key times: before eating, after using toilet,
before cooking, after changing diapers & before
Current Practices feeding others
• Most families do not treat drinking water Current Practices
• When water is treated, approximately half prefer • Adults & children wash hands at 2 key times only:
boiling & half prefer WaterGuard before eating and after using toilet
• Vast majority of families don’t store water safely

Conclusions
Behavioral Beliefs – High
Attitudes are already positive regarding POU water treatment & hand
washing and therefore should be reinforced during the campaign,
but do not need to be a central focus of the campaign.
Normative beliefs – Low
Expectations are low regarding POU water treatment
& hand washing behavior. The campaign must raise peer expectations in
order for behavior-change to occur. Normative beliefs will be
addressed through peer role modeling and a
train-the-trainer program.
Putting Theory into Action
Focus group participants had some base-knowledge regarding causes
of diarrhea and proper hygiene behaviors, however this knowledge
alone is not currently translating into proper water treatment and
hand washing behaviors. The campaign will attempt to link knowledge
and behavioral performance through application of the Theory of
Reasoned Action & Planned Behavior
Formative research findings based on the theory indicate that it is
feasible to implement a behavior-change campaign on POU water
treatment and hand washing in the Silanga Village of Kibera.

Control beliefs – Medium
Self-efficacy is moderate and can be raised by reducing barriers such as:
• Education about POU water treatment and hand washing
• Making tools that enable the behavior readily available and at a
reasonable price
We conclude that the campaign should focus on increasing self-efficacy
(control beliefs) and positive expectations (normative beliefs)
while maintaining positive attitudes (behavioral beliefs)
among women in this community.

A Case Study: Testing Campaign Ideas with a Family in Kibera

POU Water Treatment Hand washing
Leaky Tin
WaterGuard • Provided family with a
• Provided family with a portable hand washing station
one-month supply of chlorine (leaky tin) made from a locally
water treatment available container
Safe Storage Container Liquid Soap
• Provided family with a • Provided family with a one-
drinking water storage vessel month supply of locally made
with a lid & narrow spigot liquid soap
Safe Storage Container Leaky Tin

“Before you guys came here, Glen [age 2] used to have diarrhea so much.
The family tracked diarrheal episodes of three children in the household
We didn’t know what caused it. We took him to hospital, but there were no changes…
prior to and during a one-month case study. Diarrheal episodes were
Now we take safe water... We can wash our hands now easier
reported daily prior to the start of the study. No diarrheal episodes were
because of the leaky tin and we can wash away the germs…
reported during the study period.
Now the children cannot be sick.” -- Helen, age 24