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Fostering the capacity of Kibera's care groups to promote wash behaviors among pregnant and lactating women

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Fostering the capacity of Kibera's care groups to promote wash behaviors among pregnant and lactating women
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Velez, Rachel Gloria ( author )
University of Florida Digital Collections
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1 online resource (75 pages) : illustrations ;

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Diarrhea ( jstor )
Diseases ( jstor )
Foams ( jstor )
Focus groups ( jstor )
Health care industry ( jstor )
Mothers ( jstor )
Potable water ( jstor )
Questionnaires ( jstor )
Water resources ( jstor )
Women ( jstor )
Sustainable Development Practice field practicum report M.D.P
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Abstract:
This research examines the fidelity of the Care Group intervention in promoting life-saving water, sanitation, and hygiene (WASH) behaviors among pregnant and lactating women in Kibera, Kenya. The program evaluation utilized the appreciative inquiry approach to evaluate how the women perceive their respective Care Group experiences, while the FOAM framework was conducted to examine the underlying behavioral determinants to sanitation change among the women. Field data were collected through administration of 75 appreciative inquiry questionnaires, 209 survey interviews, and 1 focus group. These methodologies were employed to 1) evaluate the utility of the Care Groups in providing an enabling environment promoting health knowledge and practice, and 2) analyze the underlying determinants to sanitation behavior change that hinder or catalyze the mothers\U+2019\ ability to practice the WASH curriculum. Key findings illustrate that the Care Group model is effective in empowering and motivating women to provide healthcare to their families, environmental determinants foster the value of WASH education among mothers, and that mothers would like the opportunity to access more WASH meetings within their Care Groups.
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Includes bibliographical references.
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In the University of Florida Digital Collections.
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The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.
Statement of Responsibility:
Rachel Gloria Velez.

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University of Florida
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Copyright Rachel Gloria Velez. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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035387595 ( ALEPH )
1013977907 ( OCLC )
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LD1780.1 2017 ( lcc )

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FOSTERING THE CAPACI TY OF TO PROMOTE WASH BEHAVIORS AMONG PREGNANT AND LACTATING WOMEN RACHEL GLORIA VELEZ A FIELD PRACTICUM REPORT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR A MASTER OF SUSTAINABLE DEVELOPMENT PRACTICE DEGREE AT THE UNIVERSITY OF FLORIDA Supervisory Committee: Dr. Sarah McKune, Chair Dr. Rose Lugano, Member

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PAGE 1 Every creature has its mother, its medicine, and its peace Kis wahili Proverb

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PAGE 2 C ONTENT Acknowledgements .. Acronyms Abstract 7 Introduction .8 1 Host Organization: Carolina for Kibera 9 1.1 .. 2 Geographic Background 11 2.1 Kenya 2.2 Kibera 3 The Issue: Water, Sanitation, and Hygiene 15 3.1 WASH in the Global South 3.2 WASH and Water Governance 3.3 WASH and Water Governance in Kibera 4 The Care Group Mode l 22 4.1 Mission 4.2 Organization 5 Problem Statement and Objectives 25 5.1 Practicum Objectives 5.2 Contextual/Conceptual Framework 6 Evaluation Methodology 30 6.1 FOAM Framework 6.2 Focus Group 6.3 Appreciative Inquiry Questionnaires .. ... 6.4 Surveys 6.5 Ethnographic Observations 6.6 Methodological Consideration 7 Key Findings 8 Discussion of Recommendations 9 Into the Future 10 References 11 Annex

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PAGE 3 ACKNOWLEDGEMENTS First and foremost, I would like to thank my mother for always supporting my love of academia and travel, specifically throughout Kenya. Everything I am today is because of her. I want to thank the staff at Carolina for Kibera, and the mothers of Kibera for supporting and participating in my research. It is because your generosity and hospitality that this project was made possible. Special thanks to Dr. Galloway and Dr. Noss for their continual support throughout the I also want to thank my committee chair, Dr. Sarah McKune, for guiding me throughout the preparation of my practicum report, and making the time to brainstorm and collaborate with me on this project. Many thanks also to my committee member, Dr. Rose Lugan o, who first introduced me to the wonders of Kenya within the Languages, Literatures, and Cultures department. Her guidance and mentorship throughout the past eight years has allowed me to foster a deep ap preciation for the Swahili Coast, and directly impacted my decision to fulfil my practicum in Kenya.

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PAGE 4 A CRONYMS CFK Carolina for Kibera CBO Community Based Organization CHW Community Health Worker FH Food for the Hungry FOAM Focus on Opportunity, Ability, Motivation HOD Head of Department JMP Joint Monitoring Programme MDGs Millennium Development Goals MOH Ministry of Health SDGs Sustainable Development Goals USAID United States Agency for International Development VIP Ventilated Improved Pit WASH Water, Sanitation, Hygiene WHO World Health Organization WR World Relief WSP Water and Sanitation Programme

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PAGE 5 L IST OF F IGURES AND T ABLES Figure 1: Map of Kenya Figure 3: Kibera Borders Figure 4: Kibera Settlement Figure 5: Distribution of Cause Specific Deaths in Children Under 5 Figure 6: Regional Distribution of Deaths Caused by Diarrhea Figure 7: Populations by Region Lacking Access to Improved Drinking Water Figure 8: National Distribution of Annual Child Deaths Due to Diarrhea Figure 9: Traditional Care Group Structure Figure 10: Contextual/Conceptual Framework Figure 11: FOAM Framework Figure 12: FOAM Indicators Figure 13: Water Treatment Methods Figure 14: Resources Used to Wash Hands Figure 15: WASH Topics Mothers Identified as Wanting to Know More About Figure 16: Appreciative Inquiry Question 1 Responses Figure 17: Appreciative Inqui ry Question 2 Responses Figure 18: Appreciative Inquiry Question 3 Responses Figure 19: Appreciative Inquiry Question 4 Responses

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PAGE 6 Table 1: Focus Group Participant Characteristics Table 2: Appreciative Inquiry Respondent Characteristics Table 3: Survey R espondent Characteristics Table 4: Access/Availability of WASH Resources in Household Table 5: Knowledge and Social Support from Care Groups

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PAGE 7 A BSTRACT This research examines the fidelity of the Care Group intervention in promoting life saving water, sanitation, and hygiene (WASH) behaviors among pregnant and lactating women in Kibera, Kenya. The program evaluation u tilized the appreciative inquiry a pproach to evaluate how the women perceive their respective Care Group experiences, while the FOAM framework was conducted to examine the underlying behavio ral determinants to sanitation change among the women. Field data were collected through administrat ion of 75 appreciative inquiry questionnaires, 209 survey interviews, and 1 focus group. These methodologies were employed to 1) evaluate the utility of the Care Groups in providing an enabling environment promoting health knowledge and practice, and 2) an alyze the underlying det erminants to sanitation behavio curriculum. Key findings illustrate that the Care Group model is effective in empowering and motivating women to provide healt hcare to their famil ies, environmental determinants foster the value of WASH education among mothers, and that mothers would like the opportunity to access more WASH meetings within their Care Groups.

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PAGE 8 I NTRODUCTION Furaha It is the parent who knows the joy Working in collaboration with a community based non profit organization, Carolina for Kibera (CFK), this research focuses on investigating the efficacy of health programs oper ating in resource poor areas to promote life saving WASH behavio rs among pregnant and lactating mothers. This was achieved through conducting an Care Group intervention, where I was employed to analyze how the program facilitates an enabling environment to learn WASH information, as well as to investigate the underlying determinants to sanitation behavio r change hindering or curriculum. It is therefore the aim of this practicum to contribute to the increased fidelity of the Care Group program resulting in the reduction of diarrheal disease in children under the age of five throughout the settlement of Kibera. In order to better und erstand the full scope of this research and the issues relating to WASH throughout the sett lement, key contextual background information on Kibera is also presented. The environmental framework through which Care Group members access their WASH information is analysed through discussions of the istory, legal framework, and issues relating to water governance, while the organizational structure of CFK and its Care Group program is also included. The

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PAGE 9 relevance of this research within the greater development framework is further elaborated up o n thro ugh a comprehensive literature review on waterborne illness and WASH initiatives in the Global South Following this analyses, this report presents the problem statement and practicum objectives. An in depth discussion on the design and implementation of a ll methodologies is also employed, followed by the data analysis, conclusion remarks, and program recommendations. It is intended that this report will contribute to in creasing the impact and scalability of the Care Group intervention, as well as contribut e to the global discourse on innovative water and sanitation programs. I. H OST O RGANIZATION : C AROLINA FOR K IBERA miguuni The love of a child is on the lap of the mother 1.1 O RGANIZATION AND V ISION The evaluation was conducted in partnership with Carolina for a Kibera an international 501(c)(3) non profit organization established in 2001 by founde r and ex marine Rye Barcott. The organization operates both on the ground in Kibera and at the University of North Car olina at Chapel Hill for Global

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PAGE 10 The organization utilizes a three pronged approach health, social, and economic to str ategize and operate a number programs in Kibera, including Daughters United, Care Groups, education programs, and WASH community outreach activities. The (CFK Approach 2015, p.1). Each of these programs has been designed to achieve the idea of cascading leadership, where, after a program is established community leaders assume full responsibility and leadership over the activities. CFK approaches all projects with the aim to work collaboratively to offer opportunity, not charity. This ensures the sustainability of community projects by the community members themselves. Although a small organization, CFK reaches more than 55,000 Kibera residents each year, either throug h direct community activities, scholarships, or construction of public clinics, by working through a vast network of local and international partnerships, including international non governmental organizations (NGOs), Kenya government officials, community health workers (CHWs), local gatekeepers, and school officials.

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PAGE 11 II. G EOGRAPHIC B ACKGROUND Ucheshi The laughter of a child is the light of a house 2 .I K ENYA Straddling the Indian Ocean co a st in East Africa, Kenya sits on the equator bordered by the countries of Somalia, Ethiopia, South Sudan, Uganda, and Tanzania. The geography of the country consists of plateaus, low rising plains, highlands, mountains, 224,960 square miles, over 5,000 square miles are from wat er reserves, especially within the Rift Valley. These lakes include Lake Naivasha, Lake Bogoria, Lake Victoria, Lake Baringo, Lake Turkana, and Lake Nakuru, placing Kenya within th e Great Lakes region of Africa (Kenya, 2005, p. 1). The latest census estima ted the total population of Keny a to be ~46 million people with 43% of all Kenyans estimated to be below the age of 15 and the median age of the nation to be 19.5 years old heritage is exhibited through it s representation of over 40 distinct tribes, ranging in size from the 7 million Ki kuyu people to the 500 El Molo (Kenya Demographics Profile, 2016). Figure 1: Map of Kenya

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PAGE 12 Although 75% of Kenyans rely on agriculture to make a living, only a small portion, approximately 20%, of the total land area is suitable for farming due to the arid or semiarid nature of m uch of the soil in the country (Gow, 1995, p. 7) According to the 2016 A frican Economic Outlook Report experience rapid urbanization in the foreseeable future Report, 2016, p. 24.) The African Development Bank projects the real GDP to reach 6.5% in 2017, as increased rainfall continues to enhance a gricultural production, international oil prices remain low, improved security measures have boosted tourism, and th e Kenya shilling remains strong. As the economy strengthens, so does the ability for metropolitan areas like Nairobi to provide better oppor tunities and service deliveries compared to their rural counterparts. The influx of peoples migrating from rural to urban centres is expected to quadruple by 2045, and the World Bank projects that the s more than half of the population is expected to be living in urban areas ( African Economic Outlook Report, 2016, p. 36).

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PAGE 13 characterization of housing around metropolitan centres. The inabi lity of p oor and low income families who have migrated from rural areas to access land or housing in the formal sector has resulted in population explosions in informal settlements throughout the country. In many of these settlements, r esidents do not own any legal titles to the land they live on, and are viewed by the government as squatters. Because of this no n legal status, services and infrastructure are largely absent and human rights, such as access to clean water, are overlooked (Kenya Economic Outlo ok, 2016) 2 .2 K IBERA During t he British colonial period in Kenya, the Uganda Railway Line was founded in 1899. Its construction resulted in the founding of the city of Nairobi where the railway headquarters and colonial office s were subsequently placed. Nairobi was intended to be a home for migrant workers and colonialists, the former of which were granted short term indentured labor contracts to work on the railway and fill low level administrative positions (Furedi, 1973, p. 275 290). During the period of 1900 1940, British colonists passed the 1922 Vagrancy Act -a piece of legislature Figure 3: Kibera Borders

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PAGE 14 created to limit the movement of the indentured laborers and Kenyan natives through arrests, evictions, and spatial segregation (Clayton, 1975). Africa ns were forced to live in in selected areas according to their native ethnic groups. Nu bian soldiers who had fought for the British imperialists were granted temporary rights to settle on the then densely forested plot of land (Mitullah, 1998, p. 191). The British were largely uninterested in granting permanent residency and upkeeping the se ttlement, and after independence, it became clear that the new Kenyan government also had no intention of granting land rights to the Nubians. Instead, it was declared in 1969 that the state owns the land, and all residents a re merely temporary squatters. Following independence in 1964, rural urban migration to Nairobi exploded as Kenyans felt greater incentives to move to metropolitan cities (Ekdale, 2011, p. 6 11) Over half of the estimated 4 into informal settlements buttressing the metropolitan. Kibera, widely recognized to b hosts approximately 500,000 1.5 million people living on a plot of land the siz e of Central Park. The inability to Figure 4 : Kibera Settlement

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PAGE 15 track the p recise population stems from the transient nature of people migrating in and out of Kibera (The Unseen Majority, 2009) Presently, the community is divided into 13 villages, although their distinct borders are hard to trace (figure 3). Housing in the informal settlement is extremely congested, with most residences standing 12 x 12ft and built of corrugated tin roofs and dirt floors, holding up to eight or more tenants. Kibera provides a significant a mount of cheap labour to neighbo ring urban Nairobi, but despite this economic importance, few public services, including water delivery, waste management, and electricity, are distributed throughout the settlement. Most residents lack land tenure, and inad equate water supply and sanitation services pose serious environmental challenges (Ekdale, 2011, p. 13 16). III. T HE I SSUE : W ATER S ANITATION AND H YGIENE People are born in the same way, but their lives may be different 3 .1 WASH IN THE G LOBAL S OUTH sanitation as a human right that is essential for the full enjoyment of life and all human

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PAGE 16 The explicit recognition of the human right to clean water and sanitation was formally adopted by the United Nations General Assembly in 2010 through Resolution A/RES/64/292 (Resolution 64/292, 2010, p. 1 3). On the heels of the 2015 Millennium Development Goals deadline, this resolution was implemented to address the staggering rates of morbidity and mortality caused from water, sanitation, and hygiene (WASH) related diseases, which are estimated to contribute to 10% of the total global burden of disease (Pruss Ustin et. al., 2008, p.7) Although extremely preventable and treat able, waterborne illnesses such as diarrheal disease persist as global killers. Diarrh ea has been defined by the World Health Figure 5 : Distribution of Cause Specific Deaths in Children Under 5 ( based on data from Wardlaw et. al., 2010, p. 5) Figure 6 : Regional Distribution of Deaths Caused by Diarr hea ( based on data from Wardlaw et. al., 2010, p. 6)

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PAGE 17 more th an normal for an individual (Di arrheal Disease 2013). This illness is a symptom of an intestinal tract infection caused by ingestion of bacterial, parasitic or viral organisms, often from f ecal oral transmission. As Jamison et. al. cites, the infection spreads through contaminated food and water o r through person person contact, resulting in 1.7 billion diarrh ea cases each year (Jamison et. al. 2006 p. 415 ). Unequipped with the immunological resources to prevent and fight the illness, diarrheal disease persis ts as the second leading killer of children under the age of five, accounting for the deaths of more than 2 ,000 children each day (figure 5 ) and 800,000 annually (Wardlaw et. al., 2010, p.5). In addition to causing mortality, diarrh ea is also the leading c ause of malnutrition in children Contributing to this global burden of waterborne illness are issues relating to the access and availability of improved water, sanitation, and hygiene resources, specifically in the global South, where it is estimated tha t 80% of the total diarrh ea mortality occurs in Southeast Asia and Africa alone (figure 6 ). As stated by the WHO/UNICEF Joint Monitoring Programme (JMP), the difference between improved and unimproved ecal contamination is sep arated from human contact ( Refining the Definitions 2015 ). (For example, flush toilets are considered an improved source, while open defecation sites are unimproved sources.)

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PAGE 18 While 2.6 billion people are estimated to have gained access to improved drinking sources since 1990 663 million people worldwide continue to lack access to clean drinking water, with the majority of this population living in Sub Saharan Africa (figure 7) A 2015 JMP report estimated that 2.4 billion people worldwide lack access to improved sanitation facilities, such as flush toilets or ventilated improved pi t (VIP) latrines, further compounding the risk factors of waterborne illnesses such as diarrheal disease. Resulting from a combination of increased population growth and slow development progress, less than 17% of the population of sub Saharan Africa has g ained access to basic sanitation facilities since 1990, resulting in the increase of the practice of open defecation in this regi on. In terms of hygiene behavio rs, available data from 38 Sub Saharan Afri can countries report that the total population practi cing handwashing 0 50 100 150 200 250 300 350 Sub-Saharan Africa Southern Asia Eastern Asia South Eastern Asia All other regions Population in Millions Proportional Distribution of Populations Lacking Access to Improved Drinking Water, by Region Figure 7 : Populations by Region Lacking Access to Improved Drinking Water (K ey Facts from JMP Report, 2015)

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PAGE 19 3 .2 WASH AND W ATER G OVERNANCE IN K ENYA The CIA World Fact Book reports that as of 2015, 82% of the urban population of Kenya has access to an improved drinking water source, while only 57% of the rural population is able to access clean water. In terms of sanitation facility access, only 30% of the entire population of Kenya has access to improved sanitation facilities. It is ne diseases. As the figure illustrates, of the global child deaths due to diarrheal disease occur in just 15 countries, with Kenya t opping that chart at number 10 ( Wardlaw et. al., 2010, p. 15) arrangements, as its provision of water throughout the country is consistently characterized by low coverage, unreliability, corruption, and maintenance neglect. The failures of the s tate to provide this basic human right disproportionately affect the rural and urban poor where in the latter population it is estimated that 40% of the Figure 8: National Distribution of Annual Child Deaths Due to Diarrhea (Wardlaw et. al., 2010, p. 15)

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PAGE 20 population of Nairobi does not receive a 24 hour supply of household water (Brocklehurst, 2005, p. 1 7 ) Over 50% of water distributed into the capital from the due to physical leakages, water theft, and failures to bill (p. 8) This weak institution further compounds the cases of illegal water connections, where it is reported that only about 42% of the total households in Nairobi obtain their water legally. Urban poor, including Kiberans, largely rely on illegal connections, high priced private kiosks, or physical collection from the Nairobi Ri ver (p. 9) 3 .3 WASH AND W ATER G OVERNANCE IN K IBERA Diarrheal disease persists as a leading killer of children under the age of five in Kibera, second only to upper respiratory infection. The United Nations Economic and Social Council (UN ECOSOC) found that 24% of all households in Kibera have year round access to piped water forcing households to utilize rain catchments or access their household water from the polluted Nairobi River. This latter form of water access is considered to contribute heavily to the burden of waterborne illness in Kibera, as most shallow that when it rains they fil l up and overflow into Nair ). A 2008 report on Sanitation and Hygiene in Kibera Slums argue in Kibera is more so a crisis of governance, rather than a crisis of water scarcity (Mercy, 2008, p. 16) Weak policies and poor water management have resulted in the virtual absence of water, sanitation, and hygiene services for residents of Kibera,

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PAGE 21 as it is estimated that only 25 km of piped water networks exist throughout the entire settlement. The Water and Sanitation Program (WSP) cites several reasons for this inequitable distribution in Kibera: weak institutional capacity of Nairobi Water Utility reluctance of the company to produce water into the settlement due to the fear that much of it will be stolen, low payment rates by kiosk operators, and the provisional bias e both political influence and revenue (Brocklehurst, 2005, p. 8) Although access to clean water and sanitation facilities are limited throughout Kibera, the promotion of simp le, cost effective WASH behavio rs can greatly reduce th e burden of waterborne illness, especially among children. It is estimated that h andwashing with soap before food preparation, before consumption, after defecating, greatly reduce the incidence of diarrh ea by 42 4 7% (Curtis et. al., 2003, p. 275) Through their Care Group intervention, CFK targets expecting mothers to promote critical handwashing moments during pregnancy and development that children cts of (Spears, 2013)

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PAGE 22 IV. T HE C ARE G ROUP M ODEL A mother is for her child, the child is for its mother 4.I M ISSION Data estimate approximately 130 million live births occur worldwide each year. Four million of these babies die within their first weeks of life, half of which die within the first 24 hours after birth ( You et. al. 2015, p. 2276 ). According to the World Health Organiz ation (WHO) 4.5 million under five deaths occurred within the first year of life in 2015, accounting for 75% of all under five deaths. WHO further cites the African region as having the highest risk of a child dying before completing the first year of lif e, where 55 out of 1000 live births die in the first year. This is five times higher than the European region, where only approximately 10 out of every 1000 live births do not complete their first year of life In terms of maternal health, 500,000 women wo rldwide die each year due to pregnancy complications. Approximately 90% of these maternal and under five deaths are concentrated in developing countries, including Kenya. ( p. 2279 ). Global health professionals agree that nearly 6 million women and children can be saved each year through low cost community based interventions. Formed by the World Relief organization and further established by Food for the Hungry, the Care Group model was created b y international organizations in response to these high rate s of maternal and child mortality in the global South Further global

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PAGE 23 drivers for its adoption in over 20 countries, including its implementation in Kibera, include the Millennium Development Goals and the Sustainable Development Goals, which promote the i deal of good health and wellbeing for all. Adopted into their strategic plan in 2014, CFK operates the Care Group model as a free community health intervention targeting several maternal and child health issues plaguing Kibera. In addition to providing modules on family planning, exclusive breastfeeding, antenatal care, and vaccinations, this intervention also focuses on the promotion of WASH education to address the high rates of waterborne morbidity and mortality throughout Kibera The WASH curriculum distributed through the Care Groups include the topics of critical handwashing moments, causes/prevention/treatment of diarrheal disease, disposal of feces, and water treatment. 4.2 O RGANIZATION The Care Group Model, as illustrated below, is a community mobilization network which incorporates various levels of organization and instruction. Each structural layer of the Care Group oversees the next layer, creating a multiplying effect. Traditionally, the intervention integrates community health workers (CHW s) to train local women and former traditional birth attendants (TBAs) to become Care Group Promoters, who are then tasked with the responsibil ity of recruiting 10 15 neighbo rhood women to become members of the intervention. This traditional Care Group model structure includes a tier Promoters The CFK model, however, has chosen to eliminate this operational level and instead utilizes Head o f Department (HOD) of Health Services Mark Muasa, to

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PAGE 24 provide oversight to the other levels within the model. Further, the Promoters act as was in response to the amount of resourc es both human and physical, available to CFK, and has proven to be an effective strategy. estimate d 500 Kibera women. Meetings are held by Promoters 2 4 times a month, and usually take place within the homes of the Promoters themselves to save on venue costs. The se ssions last from 1 2 hours and facilitate maternal and child health curriculum adopted from the Core Group manual, which was created by several NGOs including the US Agency for International Development (USAID) and World Relief (WR). V. P ROBLEM S TATEMENT AND O BJECTIVES Figure 9: Traditional Care Group Structure (Perry et. al., 2015, p. 2)

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PAGE 25 VI. P ROBLEM S TATEMENT AND O BJECTIVES A child at home is a fountain of joy 5 .1 P RACTICUM O BJECTIVES conducted in response to Mark Muasa concern for intervention fidelity i n terms of facilita ting WASH knowledge and behavio r edu cation, as a recent program evaluation conducted by Curamericas and the Ronald McDonald House Charities revealed several WASH knowledge behavio r gaps among the mothers. I was therefore tasked with the responsibility of working with CFK to understand ways we could foster the capacity of the Care Groups to better educate mothers on the importance of practicing life saving sanitation and hygiene behavio rs To achieve this goal, the following two research objectives were designed : Objective 1 : Contribute to increasing the effectiveness of the Care Groups in facilitating WASH curriculum through ana lysis of the underlying behavio ral determinants to sanitation behavio r change O ne of the concerns shared with me regarding the WASH curriculum promoted through the Care Groups to day lives. For example, women are educated on critical handwashing moments which are to be perfor med with running water and soap. Without access to either or both of these

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PAGE 26 resources, this activity which is taught within the curriculum cannot be performed. It is determin a nts to sanitation behavior chang e that hinder or catalyze the practice of the Care Group curriculum. Objective 2 : Evaluate the utility of the Care Groups in providing an enabling environment promoting health knowledge and practice life saving maternal and child healthcare information was outlined to me by Yunus designed to create a comfortable, welcoming environment empowering its members to become healthcare leaders within their own households. Education lies at the foundation of the intervention, and it is the intent of CFK to promote a robust and holistic health curriculum that f its the needs of the women it serves. This objective was therefore designed to examine the environment of the meetings themselves, as well as inform on any knowledge gaps t hat need to be addressed within the curriculum. 5 .2 C ONTEXTUAL /C ONCEPTUAL F RAMEWORK The conceptual/contextual framework developed for my field practicum (figure 10) graphically depicts the social, political, and economic structures relationships, and int ended outcomes of my research in Kibera. To adequately evaluate the effectiveness s of WASH knowledge and behavio r, the overall picture of

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PAGE 27 the environment in which these groups operate must also be understood. The framework has therefore been divided into the enviro nmental, group, and individual layers to better navigate the complexities of Kibera and to understand how these different dimensions affect WASH behavio r among Care Group mothers The environment includes the political, economic, and social structures encompassing Kibera society and how these disciplines affec t the healthcare delivery systems, or absence thereof Effective and continual M&E of these layers is vital to under stand the continual and complex flux of the informal settlement in order to adapt the planning and implementation of the Care Groups accordingly. This element of the framework was carried out prima rily through literature reviews and in field ethnographic o bservations The second structure to consider is at the group level, which sets out to understand the organizational and operational components of the Care Groups This aspect was primarily conducted through an investigation of the enabling envir onment promo ting WASH knowledge and behavio r and is key to understanding the strengths and weaknesses of the communication strategy utilized by the Care Groups. The final structure considered within the practicum framework was at the individual level, and inve stigated the underlying behavio ral determinants to sanitation change among the Care Group mothers. What norms, social support systems, attitudes, and belie f s govern the Kibera and how do these determinants catalyse or hinder the opportunity, ability, and motivation to practice these life saving behavio rs promoted within the Care Group model ? For this area of the

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PAGE 28 evaluation the FOAM framework was primarily utilized, and will be elaborated upon during discussion on evaluation methodologies. The entirety of the conceptual/contextual framework is encompassed in the ongoing activity of M&E which is vital for CFK to understand how and why different institutional levels of the environment, the group, and the individual interact with one another and ultimately affect the efficacy of the Care Group intervention to promote WASH.

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PAGE 29 Environmental Level Group Level Individual Level Outcome Figure 10: Contextual/Conce ptual Framework Society Governance Economy

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PAGE 30 VII. E VALUATION M ETHODOLOGY A parent never gives up 6 .1 FOAM F RAMEWORK FOAM (focus on opportunity, ability, and motivation) is a conceptual framework aluation of handwashing behavio Global Scaling Up Handwashing Project to understand the low rate of hand hygiene practices reported across the globe A study in Kenya found that while 71% of participants understood the importance of handwashing following defecation, only 31% actually performe d the behavio r FOAM therefore provides researchers and program coordinators an understanding of the behavio ral determinates resul ting in these knowledge behavio r gaps, promoting the ability of interventions to generate sustainable increases in hygiene behaviors (Coombes et. al., 2010, p. 6 12) Figure 11: FOAM Framework

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PAGE 31 The FOAM framework presents four main categorical variables influencing individual choices to perform WASH behavio rs: opportunity, ability, and motivation. The determinant of opportunity sets out to investigate whether or not a person is equipped with the re sources to perform a behavio r through analysis of availability/accessibility, produ ct attributes, and social norms. Because this research into the Care Groups included a broad a nalysis of topics other than just hand hygiene, the variable of product attri butes was eliminated The opportunity determinants were revealed through investigation of the following questions: What sanitation and hygiene social norms exist nd a re sanitation and hygiene products/ services available and accessible to the Care Group members? The two ability determinants in FOAM are knowledge and social support. For this part of the analysis, indicators were designed to answer the following questions: What knowledge resources exist promoting WASH knowledge and practice? And How do family member, friends, neighbo rs, and other social support systems effect the sanitation and hygiene practices of group members? The final categorical variable in FOAM is motivation, and seeks to understand the attitude and beli efs, expectations, intentions, and threats tow ards performing hygiene behavio rs. It w as through this analysis that indicators were framed to understand outco mes to practicing th ese behavio rs, and why or why not they intended to do so. Figure 12 below illustrates the se indicators which were employed within the survey and focus group to perform the FOAM evaluation with the Care Groups.

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PAGE 32 FOAM Determinant Indicator Opportunity Availability of soap and water Type of toilet facility used Main source of household drinking water Availability of year round household water Resources used to wash hands Water treatment methods Presence of special place to put soap Care Group WASH meeting availability Main means of defecation for children 0 59 months Social mores of hygiene and environmental cleanliness Ability Understanding of what water, sanitation, and hygiene means Causes of diarrhe a Diarrh ea prevention methods Symptoms of diarrh ea Effective ness of Care Group WASH meeting Topics discussed at meeting Presence of handwashing resources in households of friends, fami lies, neighbo rs Encouragement of WASH behavio rs in community institutions Role of CHWs Motivation Attitudes towards water, sanitation, hygiene Perceived importance of WASH knowledge Effects of WASH on personal and child health Perceived outcomes of practicing sanitation and hygiene Figure 12: FOAM Indicators

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PAGE 33 6 .2 F OCUS G ROUP Design In order to address objective 1, the FOAM framework was employed through the implementation of a focus group with five Care Group members. The purpose of the focus group was to hold an open forum for these women to discuss their own perceived opportunities, abilities, and motivations as outlined by the FOAM framework, to practice the WASH behavio rs taught through the curriculum and how thes e determinants hinder or catalyse this behavio r change. A total of 15 questions were introduced throughout the entirety of the focus group, including questions on access to sanitation and hygiene products and facilities (clean water, latrines, soap, etc. ), what support systems they have throughout their communities to use, learn about, and access these products, how they perceive their r, and what they believe are the different threats and opportunities to practicing WASH best practices for themselves, their children, and their community. Implementation Yunus Mohammad chose the five focus group participants based on their reputation as dedicated Care Group members, their high level of participation within th eir Care Group meetings, and their length of membership extending over one year. Respondent characteristics of the focus group participants are detailed in the table below.

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PAGE 34 n= Percent Age Less than 18 years 0 0% 18 35 years 4 80% 36 49 years 1 20% Will not disclose 0 0% Total 5 100% Length of Membership Less than 1 month 0 0% 1 5 months 0 0% 6 11 months 0 0% 1 2 years 5 100% Total 5 100% Pregnancy Status Pregnant 3 60% Not Pregnant 2 40% Unsure 0 0% Total 5 100% We held the focus group at the Tabitha Health Clinic conference room, a familiar facility where all the participants were encouraged to bring their children. The session lasted approximately one hour. With the consent of the members the focus group was re corded and saved in a discreet location with a code name to ensure the privacy of the participants. Most the session was conducted in English, but to ensure that the women were comfortable in the discussion, Swahili was also encouraged. Therefore, I worked closely with a translator during the session, and afterwards to help with the transcription. Table 1: Focus Group Participant Characteristics

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PAGE 35 It is important to note that the focus group activity resulted in the design of the appreciative inquiry questionnaires a methodology I had not intended to use Towards the end of the focus group session, the women began discussing how they were interested in my evaluation and wanted CFK to hear about their experiences with their own respective Care Groups. This discussion subsequently led to the design and impl ementation of the appreciative inquiry questionnaires, which will be discussed in detail below. 6.3 A PPRECIATIVE I NQUIRY Design As discussed above, a questionnaire was designed i n response to the focus group to talk to CFK about their respective Care Group experiences. In order to align this methodology with the overall goal of the evaluation, I adopted an appreciative inquiry approach to the design of the questionnaire. Indicators were created to reflect affirmative topic choices were created to promote a positive and collaborative body of answers contributing to the capacity of the Care Groups to pro mote WASH knowledge and behavio r. Keeping in line This methodology was therefore utilized to investigate what the mothers value most about their Care Group exper iences, and how CFK can work to promote the The appreciative

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PAGE 36 inquiry questionnaires also provided a space for members to speak candidly about any suggestions they may have that would imp rove their individual memberships. Implementation The appreciative inquiry questionnaires were administered to 75 women with Care Group memberships of at least one year and were embedded within the last section of the survey interviews. Respondent chara cteristics of the appreciative inquiry respondents are illustrated in figure 14 below. Each question was approved by Yunus to ensure their alignment with the evaluation objectives Due to language barriers, Yunus Mohammad and I recruited five Promoters to conduct the questionnaires throughout the villages of Kianda, Soweto West, and Gatwekera. These five Care Group Promoters were chosen due to their long standing relationship with CFK and their dedication to the intervention. Ea ch of these women have been working with the Care Groups since their implementation in 2014, and they themselves each op erate up to 5 different neighbo rhood Care Groups per week. They were trained on how to facilitate the questions, how to record the free response answers, and how to ensure the mothers of their total anonymity Together, we reached 5 7 women per day. Each questionnaire was numerically coded and stored in a locked cabinet at the CFK office. They were categorically organized according to the qualitative responses, and raw data were collected in an Excel spreadsheet

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PAGE 37 6.4 S URVEYS Design In o rder to address objectives 1 and 2, surveys were conducted with 209 Care group members to achieve a significant sample size of the total membership of 500 mothers. Respondent characteristics of survey respondents are detailed in figure 15 below. n = Percent Age Less than 18 years 2 3% 18 35 years 67 89% 36 49 years 4 5% Will not disclose 2 3% Total 75 100% Length of Membership Less than 1 month 0 0% 1 5 months 0 0% 6 11 months 54 72% 1 2 years 21 28% Total 75 100% Pregnancy Status Pregnant 19 25% Not Pregnant 55 73% Unsure 1 ~2% Total 75 100% Table 2: Appreciative Inquiry Respondent Characteristics

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PAGE 38 With the help of Yunus Mohammad, indicators were designed to evaluate both determinants to sanitation behavior change as mapped out by the FOAM framework. The surveys were divided into four sections (not including the appreciative inquiry questionnaire), and included 25 total indicators (not including respondent characteristics), relating to WASH knowledge and behavioral determinants. Questions on the causes, symptoms, and treatment of diarrheal disease were used as indicators to and fecal disposal methods, and frequency of critical handwashing moments were used as indicators to evaluate the underlying behavioral determinants to sanitation change. n = Percent Age Less than 18 years 4 2 % 18 35 years 190 91 % 36 49 years 12 6 % Will not disclose 3 1 % Total 209 100% Length of Membership Less than 1 month 23 11 % 1 5 months 53 25 % 6 11 months 64 31 % 1 2 years 69 33 % Total 209 100% Pregnancy Status Pregnant 107 51 % Not Pregnant 98 47 % Unsure 4 ~2% Total 209 100% Table 3: Survey Respondent Characteristics

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PAGE 39 Implementation Because the appreciative inquiry questionnaires were randomly included into 75 of the surveys, the same five Promoters who conducted the questionnaires also administered the surveys. To ensur e full coverage of each of the three villages where the Care Groups operate, Yunus chose three promoters to conduct the surveys in Gatwekera (the largest of the villages CFK targets), one promoter to work in Kianda, and one to work in Soweto West. Following recruitment I conducted a training session on May 30, 2016, at Tabitha Health Clinic with the promoters to explain the overall goal of the survey, what was expected of them as interviewers, the survey structure, and the time frame in which the s urveys were to be conducted. They were instructed to conduct two practice surveys the following day (Tuesday, May 31st) and return them to CFK to be reviewed by Yunus and myself. During this review period, we gathered all the promoters and held a follow u p meeting to discuss any obstacles, questions, or concerns they had with conducting the survey. We also held a mock interview with the promoters to assess the strength of their translations of the survey into Kiswahili. Each promoter was then given the tas k of completing a total of 40 interviews over the course of five days. In total, they carried out 211 surveys which were then delivered to me.

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PAGE 40 6 .5 E THNOGRAPHIC O BSERVATIONS Implementation The most interactive of the met hodologies employed this summer were ethnographic observations, which were utilized throughout every practicum activity conducted. However, ethnographic observations were specifically utilized to achieve Objective 2 through supporting the appreciative inquiry results. I was invited to at tend a total of 10 Care Group meetings to observe the enabling environment and communication strategies utilized to facili tate WASH knowledge and behavio r In order not to hinder the success of the meetings, I encouraged the Promoters to facilitate the sessions in Swahili and to continue as if I were not even there. I often sat in the corner of the meeting place and re corded many components of the sessions, including : number of pa rticipants, number of participants who arrived late, number of participants who had to stand, frequency of topics discussed etc. 6.6 M ETHODOLOGICAL C ONSIDERATIONS Overall, the amount of support that I received from Yunus Mohammad in executing the differ ent methodologies yielded terrific results a nd insights into the structure and strategic communication plan of the Care Groups, as well as the underlying determinants to and knowledge transfer of the Care Groups. It is important to note, however, that cer tain obstacles did arrive throughout the different processes. Due to the pers onal nature of the survey and appreciative inquiry questionnaire, which probed into the ways the mothers provide healthcare for their children, the promoters

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PAGE 41 shared with me on a c ouple occasions the unwillingness of certain mothers to participate in the exercises. P articularly in discussing the appreciative inquiry questionnaire, promoters revealed to me that some mothers fe lt uncomfortable discussing the negative experiences with their Care Groups, which provided them with free healthcare knowledge and support for themselves and their children. Also, there were a few times where I could not keep the focus group discussions on topic, and we veered onto different tangents, spending n o less than twenty minutes discussing how the Care Group mothers wanted me to ask CFK to implement a microfinance club for them. There were other instances where the Care Group mothers believed I had the several issues including when they would ask me to discuss with CFK the possibility of compensating the mothers for attending the Care Group meetings VIII. K EY F INDINGS Health is a crown and no one knows it save a sick person Objective 1 : Contribute to increasing the effectiveness of the Care Groups in facilitating WASH curriculum through analysis of the unde rlying behavio ral det erminants to sanitation behavio r change In order to foster the capacity of the Care Groups to promote a relevant, effective WASH curriculum, an assessment of the underlying behavio ral determinants to

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PAGE 42 sanitation change was conducted. This evaluation was guided by the principles of the FOAM framework, in which the opportunity, ability, and motiva tion of the mothers to practice im proved WASH behavio r was analyz ed. Opportunity The behavio ral determinant of opportunity can be understood as the effects the social and economic environment of Kibera have on catalysing or hindering sanitation behavio r change as taught throughout the Care Group curriculum This opportunity analysis was conducted through identifying the social norms governing water, sanitation, an d hygiene practices of the Care Group mothers, and through evaluating the availabili ty and accessibility of sanitation and hygiene products/services in these neighborhoods The social norms discussed throughout the focus group focused on the mores of self hygien e and environmental cleanliness that motivate the women to practice WASH behaviors. Throughout this discussion, the words hygiene, wash (as in hands and body ), and clean/cleanliness, were utilized to describe interactions with their surrounding environment and hygiene among their own bodies. As reported by one re spondent: we just talk about

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PAGE 43 sanitation, personally. It is something personal. You do it for yourself to obtain Th e topic of environmental cleanliness included discussion among the mothers of how important it is to wash hands after contact with toilets and latrines, because as one importance of hand hygiene when in contact with the physical environment of Kibera. This was explained by one mother: you use the bathroom, you need to wash your hands. When you go to feed the There was consensus on how the proper use of toilets, riversides, and dams can promote a healthier environment and reduce sickness within the community. In te rms of drinking water, 100% of the women reported that they boil or add chlorine to ensure 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Boil Add chlorine/Camphor Strain through cloth Let stand and settle Water Treatment Methods Figure 13: Water Treatment Methods

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PAGE 44 its potabili ty. As one mother commented: This social norm of treating drinking wa ter is further identified by analyz ing data from the survey. As figure 16 shows, boiling water and adding chlorine were indicated as the most utilized treatment methods among the survey respondents. Both focus group data and survey results further informed on the access and availability of sanitation and hygiene products and services throughout Kibera. When asked what they felt is the best thing about living in Kibera, all five women referenced the accessibility and affordability of various goods a nd amenities. In terms of soap, the women discussed its visibility and affordability within their markets. Describing this accessibility, one woman stated: These responses are further corroborated within the survey data, as 98% of the woman surveyed indicated using soap when washing their hands (figure 17 ). 0% 10% 20% 30% 40% 50% 60% 70% 80% Running water only Settled water only Running water and soap Settled water and soap Resources Used to Wash Hands Figure 14: Resources Used to W ash Hands

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PAGE 45 The underlying determinant of access and availability to water in Kibera is more complicat ed to understand, as it is largely contingent on the interaction of economic and environmental factors. As the figure 18 shows, 94% of the 209 survey respondents access pipe borne water for their household uses. Of these women, however, only 66% reported they have year Access/Availability in Household n= Percent Main source of HH drinking water Pipe borne water 202 94% Sachet/bottled water 4 2% Hand pump well 4 2% Bore hole 0 0% Rain from roof 4 2% River/stream/swamp/ dam/pond 0 0% Will not disclose Total 214* 100% Year round water availability in HH Yes 138 66% No 71 34% Total 209 100% Toilet facility used by HH Bush/field 18 8% Flush 49 21% VIP latrine 53 23% Covered pit latrine 57 25% Uncovered pit latrine 32 14% Public toilet 15 6% Flying toilet 7 3% Total 231* 200% Resources used to wash hands Running water only 4 2% Settled water only 2 ~0% Running water and soap 176 74% Settled water and soap 56 24% Total 238* 100% *Respondents indicated more than one response Table 4: Access/Availability of WASH Resources in Household

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PAGE 46 As discussed in the focus group, Nairobi Water and Sewage recently began providing water services to Kibera in the form of a main 2 pipe system. Since its implementation, this system has been largely bought out by private vendors, who, in some way or another, obtained complete control of the water entering Kibera from the one focus group participant described it) flu ctuations in prices. Private vendors capitalize on regional water scarcities mainly due to drought and force Kiberans to pay upwards of 10 times the price of water that Nairobi urban residents pay. As one focus group participant commented: While water may be available, it is not entirely accessible to the women due to its cost. The opportunity analysis of underlying behavio ral det erminants to sanitation behavio r change revealed the fol lowing: Women live in a community where the importance of environmental cleanliness and personal hygiene are understood Soap is identified as easily accessible, available, and widely used While water is identified as being available in Kibera, its accessibility is largely contingent on its affordability

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PAGE 47 Ability The behavior al determinant of ability can be understood through answering the following two questions: What educational resources exist promoting WASH knowledge and practice? And how do f am ily members, friends, neighbo rs and other social support systems affect the sanitation and hygiene practices of group members? In terms of knowledge and social support provided by the Care Group meetings, figure 19 illustrates survey responses from the 209 participants regarding the ability of the WASH curriculum to facilitate sanitation behavior change through evaluation of the following indicators: WASH meeting attendance, length since last WASH meeting was provided, perceived effectiveness of meeting, and topics discussed. Knowledge and Social Support from Care Groups n= Percent Very Important 196 93% Somewhat important 12 6% Not very important 0 0 Does not wish to answer 1 ~1% Total 209 100% Has attended a Care Group Meeting on WASH Yes 180 86% No 29 14% Total 209 100% Length since last WASH meeting Within the past month 88 42% 1 2 months ago 63 30% 2 3 months ago 17 8% More than three months ago 37 18% Does not remember 4 2% Total 209 100% Perceived effectiveness of WASH meetings Very effective 193 93% Somewhat effective 13 6% Not very effective 0 0%

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PAGE 48 Does not remember 3 1% Total 209 100% Topics discussed in WASH meetings attended Critical handwashing moments 99 53% Causes of diarrhea 86 46% Symptoms of diarrhea 88 47% Treatment of diarrhea 78 41% Handwashing with soap 59 31% 23 12% All of the above 82 44% None of the above 1 1% Other 1 1% Total 517 276% Indicated desire to learn more on WASH Yes 70 33% No 139 67% Total 209 100% As the table illustrates, 93 % of participants indicated their meetings on WASH to WASH curriculum includes the education of critical handwashing moments, caus es/symptoms/ treatment of diarrh ea, handwashing with soap, and disposal of 19 shows, however, relatively low percentages of respondents reported learning about these issues throughout their WASH meetings Data further show that only 44 % of women were educated on all WASH curriculum topics An interesting trend revealed itself through analysis of the surveys, in which 32 Table 5: Knowledge and Social Support from Care Groups

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PAGE 49 of the 70 respondents who indicated they wanted to learn more about WASH described the topics they were interested in (figure 20 ) As illustrated in figure 19 86% of Care Group women surveyed have attended a meeting on WASH, with 93 % of these surveyed w omen indicating WASH education to be for the Care Groups to capitalize on this reported high attendance rate and desire among Care Group women to educate themselves on WASH through broader coverage of topics during meetings. Increasing the efficacy of this knowledge base to promote water, sanitation, and hygiene best practices promotes the ability of the mothers to achieve wellbeing for themselves and their children. In terms of the effect of social support systems on the promotion or discouraging of sanitation and hygiene practices, focus group participants discussed the role of community health workers (CHWs) in disseminating important knowledge and resources to h ouseholds throughout Kibera. Their door to door education on critical handwashing Figure 15: WASH Topics Mothers Identified as Wanting to Know More About 0% 5% 10% 15% 20% 25% 30% 35% Water purification Diarrhea prevention WASH in general Treating diarrhea Topics Mothers Want to Know More About

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PAGE 50 moments was reported by the participants as being a valuable resource to learn about WASH. The women also referenced a recent campaign facilitated by CHWs in which handwashin g kits, including soap and soap holders, were delivered to hundreds of households throughout Kibera. The other two social support systems highlighted in the focus group were media many resources where you can hear such things [on WASH]. Like radios they did a campaign for the hygiene education. In school, we were The ability of the women to access knowledge resources and support can be understood as the role the Care Group education plays in disseminating WASH knowledge, as well as the fostering of support from CHWs, media campaigns, and schooling. This ability analysis has identified the following: Care Group women have the abili ty to learn about WASH in their Care Groups, but curriculum could be scaled up to cover more subject matter ; meetings can also be provided more frequency to increase WASH education CHWs are valued among the mothers as a source of suppo rt promoting sanitation behavio r change Various other social support systems exist that foster proper sanitation and hygiene practices taught in the WASH curriculum

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PAGE 51 Motivation The motivation analysis of the underlying det erminants to sanitation behavio r change was conducted to understand the beliefs and attitudes representing the Focus group participants expressed a positiv e attitude towards WASH behavio rs, citing their abilities to promote wellbeing and reduce financial burden. In terms of and just throw it in the streets. Sometimes a child will come and play with the This belief in the ability of p racticing improved WASH behavio rs to reduce illness was also described in a discussion of keeping the house and surrounding environment clean. As describe d by another mother: Mo tivation to practice sanitation and hygiene was also understood in financial terms as having the ability to reduce expenditures on treatment and hospital bills. An anecdote was shared by one of the focus group participants, and described how her mother wou ld always be stressed out when a child beca me ill with diarrh ea because of the costs

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PAGE 52 of treatment. Her experiences as a child witnessing this familial burden was expressed as her motivating factor to ensure the cleanliness of her body and her household: be so stressed out. You avoid that stress, you keep yourself clean, your house It can therefore be understood that these mothers ide ntified practicing WASH behavio rs as having the positive outcomes of preventing illness and reducing financial stress. This motivational analysis, although brief, highlights the positive attitudes of mothers towards WASH education, and should be capitalized by CFK through increased facilitation of meetings pertaining to the issues of sanitation and hygiene. As figure 19 illustrated, only 42% of the 180 women who indicated they had attended a WASH meeting reported that it was offered within the last month, with most respondents indicating their WASH meeting had occurred 2 or more months ago. Scaling up the provision of WASH meetings would therefore meet the needs of these women, who have reported positive attitudes and outcomes relating to sanitation behavio r change. This analysis has therefore highlighted the following: Mothers are motivated to access WASH education within their Care Group meetings Mothers p ositively perceive WASH behavio r as a means to reduce waterborne morbidity within their families Mothers inten d to practice sanitation and hygiene to reduce financial burden

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PAGE 53 Objective 2 : Evaluate the utility of the Care Groups in providing an enabling environment promoting health knowledge and practice Objective 2 was designed to investigate how the Care Group members perceive their respective meeting e xperiences in which WASH knowledge is promoted. What do these women value most about the enabling environment of the intervention, and how can CFK improve and/or sus tain these positive experiences within the operational framework? Insight into the experiences of the Care Group members highlights various operational strengths and weaknesses of the intervention, and will enable CFK to better target the maternal and chil Investigation of how, why, and to what degree the Care Groups are valued among the mothers was achieved through analysis o f the appreciative inquiry questionnaire, which consisted of the following four questions: 1 What attracted you to want to join your Care Group? 2 What do you hope your Care Group family will accomplish within your community? 3 What aspects of your Care Group family are the most effective in sharing maternal and child health information? 4 What recommen dations do you have for CFK to allow for the continued effectiveness of your Care Group family? To effectively analyze the questionnaires, I categorized responses for each question into a series of themes. Graphic illustrations of these themes are provide d below, followed by an analysis of each appreciative inquiry indicator.

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PAGE 54 A total of 106 distinct responses were identified for the question of what attracted the women to join their Care Groups, which were subsequently assigned into 4 major thematic areas. As illustrated in figure 21, respondents overwhelming identified their b elief in the ability of the Care Group program to provide healthcare information for themselves and their children. Mothers cited their desire to know how to prevent and treat illness for their children, how to avoid painful pregnancies, and safe ways to d as a driver, as women acknowledged the Care Groups announce places to obtain free vaccinations, free cervical screening, and where to acquire certain medicines. 17 resp onses indicated that family members or friends had recommended the woman to join a Care Group, either for education or because they themselves had tried it and 0 10 20 30 40 50 60 70 80 Healthcare Education Healthcare Services Education Recommended by Friends/Family Convenient 1. What Attracted You to Want to Join Your Care Group? Figure 16: Appreciative Inquiry Question 1 Responses

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PAGE 55 found it effective. Convenience was also cited as a driver, and was described in terms of the pr commitment, and the ability to bring their children to the meetings. The enabling environment illustrated in these responses directly correlates with iew the Care Group environment as promoting both healthcare information and convenience to the women seeking its services. A total of 127 responses were identified for the question of what aspects of the Care Group program is viewed as most effective in sharing maternal and child health information, which w ere subsequently assigned into 3 major thematic areas. As illustrated in figure 22, women indicated their appreciation of the ability of the Care Group Promoters to facilitate knowledge in a manner that was easy to understand. Respondents contrasted their experiences going to the clinics and not being able to 0 10 20 30 40 50 60 70 Encouraged Participation Topics Easy to Understand No Judgement 2. What Aspects of Your Care Group Family are Most Effective in Sharing Maternal/Child Health Information? Figure 17: Appreciative Inquiry Question 2 Responses

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PAGE 56 understand the language used by nurses or physicians to the ease of learning the m aterial promote d in the Care Group meetings. facilitation skills was also identified as responses indicated their meetings foster a participatory environment where everyone is encouraged to introduce themselves, ask question s, and offer personal anecdotes. The ability of the Promoters to promote a participatory atmosphere is further corroborated from the ethnographic observations, where each meeting I attended I observed the mothers being asked to introduce themselves (and th eir children if present) and to share their insights, questions, and concerns throughout the entire meeting. This appreciation of the inclusive nature of the Care Group meetings extended into a third identified theme from the questionnaire responses, and i lack of judgement present when discussing the health of their pregnancies and children. A number of responses acknowledged past experiences at clinics and hospitals where the women were ashamed to discuss their heal thcare habits or lack thereof. The Care Groups, however, were indicated to be a safe space with the sole goal of promoting healthy pregnancies and active children. As one woman described in her response: The enabling environment described through these responses highlights the ability of the Care Groups to foster an inclusive, participatory, and judgement free space to discuss maternal and child healthcare topics such as WASH directly aligning with

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PAGE 57 A total of 140 responses were identified for the question of what the mothers hope their Care Groups will accomplish within their communities, which were subsequently assigned into 3 major thematic areas. The perceived ability of the Care Groups to promote healthcare kn owledge was again overwhelming indicated as a value women prescribe to their program experiences. 60 of the total responses for this question related to the respondents desire for the Care Group program to reduce the numbers of unsafe healthcare practices through education, with 27 of these responses indicating the ability of the Care Groups to empower women to learn and become educated on life saving healthcare material. 56 of the total responses for this question indicated the hope for the Care Group pro gram to ensure the health of their children through the lessons learned during the meetings. As one woman described in her response: 0 10 20 30 40 50 60 70 Healthy Pregnancies Healthy Children Increased Healthcare Knowledge 3. What Do You Hope Your Care Group Family Will Accomplish Within Your Community? F igure 18 : Appreciative Inquiry Question 3 Responses

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PAGE 58 care for the health of their families. Thank yo u CFK for giving me the knowledge 24 women also discussed their desire for the Care Groups to promote healthy pregnancies, with a number of responses again describing personal experiences with their own past pregnancies. Respondents indicat ed their appreciation of the Care pregnancy. Responses highlighted in this question belief in the ability of the Care Groups to promote healthy, active communities through dissemination of the Care Group curriculum. 0 5 10 15 20 25 30 Financial Incentives Larger Venues Interactive Media 4. What Recommendations Do You Have for CFK to Allow for the Continued Effectiveness of Your Care Group Family? Figure 19: Appreciative Inquiry Question 4 Responses

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PAGE 59 While acknowledging the ability of their groups in providing them with maternal and child health care knowledge, appreciative inquiry participants also identified three obstacles within the organizational structure of the meetings when responding to the question of whether or not they had any recommendations for CFK. All of the 44 respon ses to this question can be grouped into the three groups of where the absence of these were identified as hindering the educational success of the interve ntion Issues relating to the venue were mentioned by 11 participants throughout the questionnaire, and we re further identified during ethnographic observations Fields notes indicate that o f these ten meetings observed eight were held at the h omes of the Care Group promoters, specifically in the main living area where tables, boxes, and TV stands were transformed into seating areas for the women. Issues with these home meetings were identified as relating to inadequate provision of chairs, as o ne women reflects in her questionnaire response, Physical space was also viewed as inadequate to accommodate all Care Group members, as another woman states, This issue is further corrobo rated through observation of field notes:

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PAGE 60 Tuesday, May 17 th in living room, not enough seats for every mother, some had to stan d in doorway. Quick count identifies 13 of the 25 mothers standing in doorway. Of the observed meetings that took place in public locations, including a schoolhouse and community meeting space, adequate chairs were provided and all women were able to fit w ithin the venue. When asked to provide any recommendations to CFK that can allow for the continued effectiveness of their Care Group experience, 7 respondents also indicated their desire for media materials to better facilitate the health knowledge during th e meetings. While it was indicated by Mark Muasa that informational cue cards had been recently distributed amongst the Care Group Promoters, ethnographic observations of the meetings revealed no use of these materials. The structure of the meeti ngs was largely lecture based, and no use of supporting educational tools was observed These 7 respondents indicated that the incorporation of videos, plays, and visual handouts (such as the cue cards) would increase the ability of their Care Groups in sh aring healthcare information. As one member commented, While understanding the resource limitations of the Care Groups it is nonetheless important to reveal these obstacles to effective knowledge provision as indicated by the members themselves. These issues should be used as constructive

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PAGE 61 insights to investigate creative means to better facilitate the needs of the Care Group women. Suggest ions posed during informal interviews with Promoters included having the mothers bring a chair with them to the meetings, or holding Care Group sessions in desire for more exp ressive channels to facilitate knowledge. This need can be met through effective implementation of the cue cards, and further monitoring of other supporting tools. The desire to receive financial motivation to attend meetings was also revealed in the fiel d. When speaking with one of the mothers after a meeting, she discussed how difficult it was to leave her market stand for an hour (or longer, depending on the proximity to the venue) to attend her Care Group. This struggle was further explained by Katheri ne Wagude, a CFK employee in the health department, who explained that the women often come late to their meetings or are absent from them all together because they cannot afford to be awa y from their businesses. The que stionnaire responses revealed an arr ay of economic coping strategies presented by the women that would motivate them to attend their group sessions including microfinance clubs, small craft workshops, handing out diapers/pampers, and helping the women to access health insurance cards. Addre ssing the economic needs of the members, whether through provision of these microfinance clubs or small bead and tailoring workshops, may allow CFK to better serve the community women with critical health information.

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PAGE 62 This section provided insight into ho w Care Group members perceive their individual experiences within the intervention. Discussion of both the appreciative inquiry questionnaire and ethnographic field notes revealed the success of the Care Groups in fostering an empowering and educative envi ronment for the community women. Analysis of these methodologies also allowed a better understanding of the perceived barriers to receiving education on health topics. Through acknowledging and addressing these operational strengths and weaknesses, CFK ca n further promote the success of its Care Group model. IX. D ISCUSSION OF R ECOMMENDATIONS Health is priceless The evaluation into the CFK Care Group model revealed a number of strengths and weaknesses informing on the ability of the intervention to pro mote WASH knowledge and behavio r to its 500 member women. Through investigation of its operational framework and communication strategies it was revealed that the women saving maternal and child health information and empowering them to provide healthcare for their children. Because the Care Groups are viewed as an effe ctive space to promote the agency of mothers to be healthcare leaders within their households, as women value the inclusive and participatory nature of the lesson facilitation, CFK should consider scaling up the

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PAGE 63 intervention into other Kibera villages outs ide of Gatwekera, Soweto West, and Kianda. While perceived as an effective intervention in highlighting the importance of maternal acknowledgment that more creative facilitation mediums (skits, films, cue car d s) would increase the effectiveness of their education, specifically the graphic cue cards which have reportedly been distributed to the Promoters but are not widely used. To ensure consistent and on time attendance to the meetings, CFK should further consider aiding the women in creating cash flow networks, such as small beading clubs or microfinance/merry go round groups. The provision of these financial safety nets may wo rk to strengthen social bonds throughout the Care Group neighborhoods, allow women to control their own capital, and further empower women within the household. Investigation into the underlying determinants to sanitation change further informed on the c ommunity resources hindering or catalysing individual choices to perform WASH behavio rs as taught within the Care Group meetings These results highlight the positive attitudes projected by the mothers in wanting to learn WASH information to generate posit ive health outcomes for themselves and their children, as well as the ability of the Care Groups and other institutions to promote healthcare support networks throughout the community. The reported underlying determinants therefore foster the opportunities abilities, and motivations to put in to practice the water, sanitation, and hygiene materials learned within their meetings. However, women indicated a disconnect between their desire to learn about WASH and their

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PAGE 64 ability to access Care Group meetings on the life saving topics. CFK should therefore consider scaling up the provision and frequency of WASH meetings to meet the pertaining to water, sanitation, and hygiene, it is also recommended that Promoters may want to implement a short evaluation exercise following each meeting to understand if the lesson material was relevant and comprehensive, or perhaps lacking in some aspects. X. I NTO THE F UTURE The pride of the nation is its youth It is the hope that this report will better inform Carolina for Kibera on the fidelity it. The above recommendations are inte nded to provide CFK with the tools to foster and sustain their impact into the future to continue existing as a livelihood strategy valued among hundreds of mothers. Simple, cost effective WASH interventions such as this possess the ability to generate ser ious impact in the lives of mothers, children, and the community as a whole. My time spent with CFK has educated me on the resourcefulness, sense of community, and immense pride vibrating throughout the informal settlement, and while Kiberans may not have the same access to public serv ices as other communities, these people are not invisible. They possess the same

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PAGE 65 human rights as any other global citizen, and as stated by Carolina for Kibera: Slums are dirty. The people who live there are not.

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PAGE 66 XI. R EFERENCES African Economic Outlook 2016 (Summary in English). ( 2016). African Economic Outlook African Economic Outlook 2016. doi:10.1787/142c87c6 en Brocklehurst, C. (2005, June). Rogues No More? Water Kiosk Operators Achieve Credibility in Kibera. Water and Sanitation Program Africa, 1 12. Retrieved from World Bank. CFK. (2016). Carolina for Kibera/UNC. Retrieved 24 March 2016, from http://cfk.unc.edu/ Coombes, Y., & Devine, J. (2010, August). Introducing FOAM WSP. Retrieved November 18, 2016, from https://www.wsp.org/sites/wsp.org/files/p ublications/WSP_IntroducingFOAM HWWS.pdf Curtis, V. & Cairncross, S. (2003). Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. The Lancet Infectious Diseases. 3(5), 275 281. Diarrhoeal Disease. (2013) WHO Fact Sheet. Retrieved December 11, 2015. Ekdale, B. (2011). A History of Kibera. 1 16. Fengler, W. (2011, June). Why do Kenyans want to liv e in cities? Retrieved November 14, 2 016, from http://blogs.worldbank.org/africacan/why do kenyans want to live in cities Gow, J., & Parton, K. (1995). Evolution of Kenyan agricultural policy. Department of Agricultural Economics and Business Management, 12 (4), 2 16. doi:10.1080/03768359508439833 Jamison, D., Breman, J., & Measham, A. (2006). Disease c ontrol priorities in developing countries. World Health Organization, 44(01). doi:10.5860/choice.44 0343 Kenya Demographics Profile 2016. (n.d.). Re trieved November 14, 2016, from http://www.indexmundi.com/kenya/demographics_profile.html Kenya Food and Agriculture Organization. (2005). Re trieved November 14, 2016, from http://www.fao.org/fileadmin/user_upload/drought/docs/kenya_cp.pdf

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PAGE 67 Kenya Economic Outlook. (2016). Retrieved November 14, 2016, from http://www.afdb.org/en/countries/east africa/kenya/kenya economi c outlook/ Kenya Ethnic Groups. (1992). Retrieved November 14, 2016, from http://www.africa.upenn.edu/NEH/kethnic.htm Kenya Historical Background. (2003). EAAF Annual Report, 108. Key facts from JMP 2015 report. (n.d.). Re trieved November 10, 2016, from http://www.who.int/water_sanitation_health/monitoring/jmp 2015 key facts/en/ Mercy, K. (2008). Sanitation and Hygiene in Kibera Slu ms, Nairobi. Retrieved November 14, 2016, from http://www.waterfund.go.ke/s afisan/Downloads/Sanitation and Hygiene Kibera.pdf Perry, H., Morrow, M., Borger, S., Weiss, J., Decoster, M., Davis, T., & Ernst, P. (2015). Care Groups I: An Innovative Community Based S trategy for Improving Maternal, Neonatal, and Child Health in Resource Const rained Settings. Global Health: Science and Practice, 3(3), 358 369. doi:10.9745/ghsp d 15 00051 Prss stn, A., Bos, R., Gore, F., & Bartram, J. (2008). Saf er water, Better health: Costs, benefit s and sustainability of interventions to protect and promote health. World Health Organization, 7. Refining the definitions: An ongoing process and the ladder concept (n.d.). Retrieved from http://www.wssinfo.org/definitions methods/ Rotavirus disease and vaccines in Kenya Path. (2014 June). Retrieved November 14, 2016, from https://www.path.org/publications/files/VAD_rotavirus_kenya.pdf Spears, D. (2013). How much international variation in child height can sanitation explain? Policy Research Working Paper 6351. World Bank, USA. Retrieved from World Bank website: http://www wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2013/02/05/ 00158349_20130205082533/Rendered/PDF/wps6351.pdf THE UNSEEN MAJORITY: N SLUM DWELLERS. (2009, March). Retrieved November 14, 2016, from Amnesty International. U.N. General Assembly, 64 th 2 [The human right to water and 3. In Re solution adopted by the General

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PAGE 68 Assembly on 28 July 2010 (A/64/L.63/Rev.1 and Add.1). Official Record. Wardlaw, T., Salama, P., Brocklehurst, C., Chopra, M., & Mason, E. (2010). Diarrhea : Why children are still dying and what can be done. The Lancet, 375 (9718), 870 872. doi :10.1016/s0140 6736(09)61798 0 What is Diarrhoea and How to Prevent It. (2006, March ). Retrieved November 18, 2016, from http://rehydrate.org/diarrhoea/ WHO | Infant mortality. (n.d.). Retrieved November 14, 2016, fro m http://www.who.int/gho/c hild_health/mortality/neonatal_infant_text/en/ You, D., Hug, L., Ejdemyr, S., Idele, P., Hogan, D., Mathe rs, C., . Alkema, L. (2015, September). Global, regional, and national levels and trends in under 5 mortality between 1990 and 2015, with scenar io based pr ojections to 2030: A systematic analysis by the UN Inter agency Group for Child Mortality Estimation. The Lancet, 386(10010), 2275 2286. doi:10.1016/s0140 6736(15)00120 8

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PAGE 69 Appendix CARE GROUP SURVEY 2016 SECTION I: RESPONDENT CHARACTERISTICS RC.I What is your age? I = Less than 18 years 2= 18 35 years 3= 36 49 years 4= Will not disclose RC.2 What is your marital status? I = Single 2= Married (monogamous) 3= Married (polygamous) 4= Widowed/Divorced/Separated 5= Other (specify) _______________ ENUMERATOR: The questionnaire should be administered to Care Group mothers who are pregnant and/or who have children 0 24 months old INFORMED CONSENT Read to Respondent Hello. My name is ( NAME ), and I work with Carolina for Kibera (CFK). We are conducting a survey and would appreciat e your participation. I would like to ask you about your health and the health of your youngest child under the age of two years. This information will help Carolina for Kibera to plan health services and assess whether it is meeting its goals to improve m others and children health here in Kibera. This survey usually takes 30 minutes to complete. Whatever information you provide will be kept confidential. Participation in this survey is voluntary and you can choose not to answer any individual question or a ll of the questions. You can stop the survey at any time. However, we hope that you will participate in this survey since your views are very important. Will you participate in this survey? Yes ___ No___ ( If No, thank the person and end the visit) Thank yo u. Village_________________ Length of Care Group Membership ______________ Name of Interviewer _______________________ Date __________

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PAGE 70 RC.3 What is your religion? I = Muslim 2= Christian 3= Other RC.4 Are you currently pregnant? I = Yes 2= No 3= Not sure RC.5 When was your last pregnancy I = Over 2 years ago 2= 1 2 years ago 3= Less than a year ago 4= This is my first pregnancy RC.6 How far are you from the health facility that provides maternal and child health services? If unable to approximate distance, write name of the facility below NAME OF FACILITY I = Less than or equal to I kilometer 2= 2 kilometers 3= 4 kilometers 4= Greater than 4 kilometers SECTION 2: Diarrheal Disease DD.7 In the last 2 weeks, did any child in this household 0 24 months suffer from diarrhea? When a child goes to toilet at least 4 times within 24 hours I = Yes 2= No If No, skip to DD.13 DD.8 How many children 0 24 months old have suffered from diarrhea in the last 2 weeks? I = One 2= Two 3= Three 4= Four and above IF ONLY ONE CHILD BETWEEN 0 24 MONTHS SUFFERED FROM DIARRHEA IN THE LAST 2 WEEKS IN THIS HOUSEHOLD, CONTINUE WITH THE INTERVIEW. IF MORE THAN ONE CHILD SUFFERED FR OM DIARRHEA, SELECT RANDOMLY ONE OF THE CHILDREN AND CONTINUE DD.9 Was the child who suffered from diarrhea in the last 2 weeks given less than usual to drink, about the same, or more than usual? I = Nothing to drink 2= Much less to drink 3= Somewhat less to drink 4= About the same amount 5= More than usual 6= I do not know DD.10 Was the child who suffered from diarrhea in the last 2 weeks given less than usual to eat, about the same, or more than usual? 1= Never gave food 2= Much less to drink 3= Somewhat less to drink 4= About the same amount 5= More than usual 6= I do not know

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PAGE 71 DD.11 Was the child who suffered from diarrhea in the last 2 weeks given a drink made of special packet (ORS)? I = Yes 2= No 3= I do not know DD.12 Where did the child who suffered from diarrhea in the last 2 weeks get referred to for treatment? I = Nowhere 2= Government hospital 3= Private hospital/Clinic/Dispensary 4= Traditional healer 5= Drug peddlers (Pepper doctor) 6= Chemist DD.13 What are the symptoms that indicate the need to take the baby to the health facility immediately? You can choose more than one option I = Stops breastfeeding 2= Has difficulty breathing 3= Feels hot or unusually cold 4= Becomes less active 5= Body becomes yellow especially on the eyes, palms and soles 6= I do not know DD.14 What are the causes of diarrhea? You can choose more than one option I = Cockroaches 2= Drinking contaminated water 3= Eating contaminated food 4= Mosquito bites 5= Smoking 6= Too much sugar 7= Other (specify) ____________ 8= I do not know DD.15 How can you prevent diarrhea? You can choose more than one option I = Stop smoking 2= Use mosquito nets 3= Drink/eat uncontaminated water/food 4= Wash your hands at critical mo ments 5= Always drink pure water 6= Other (specify) ______________ 7= I do not know DD.16 What are the symptoms of diarrhea or how do you detect diarrhea? You can choose more than one option I = Frequent stooling 2= Change in color of your stools 3= Mucous, blood or fat in stools 4= Vomiting 5= General body weakness or tiredness 6= I do not know SECTION 3: WATER, SANITATION, AND HYGIENE

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PAGE 72 WS.I What is the main source of drinking water in your household? I = Pipe borne water 2= Sachet/bottled water 3= Hand pump well 4= Bore hole 5= Rain from the roof 6= River/Stream/Swamp/Dam/Pond 7= Other (specify) _____________ WS.2 Is water available from your main source throughout the year? I = Yes 2= No WS.3 What do you do to the water your household uses for drinking to make it safe to drink? You can choose more than one option I = Boil 2= Add chlorine/Camphor 3= Strain through cloth 4= Let it stand and settle 5= Other (specify) ______________ 6= Nothing WS.4 What kind of toilet facility do memb ers of your household use? You can choose more than one option I = Bush/field 2= Flush 3= Ventilated improved pit latrine 4= Covered pit latrine (with slab 5= Uncovered pit latrine (without slab) 6= Other (specify) ______________ WS.5 What is the main means of defecation for children 0 59 months? I = Flush toilet 2= VIP latrine 3= Covered toilet 4= Uncovered toilet 5= Backyard/bush/stream/river 6= Potty 7= Other (specify) ______________ WS.6 The last time (NAME OF CHILD) passed stool, how did feces? I = Threw into flush toilet 2= Threw into VIP/covered latrine 3= Threw into uncovered toilet 4= Threw at backyard/bush/stream/river 5= Other (specify) _____________ WS.7 When do you usually wash your hands? You can choose more than one option I = After visiting the toilet/defecation 2= After cleaning babies bottom 3= Before food preparation 4= Before eating

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PAGE 73 5= Before feeding children 6= Other (specify) _____________ WS.8 What do you use to wash your hands? I = Running water only 2= Settled water only 3= Running water and soap 4= Settled water and soap 5= Other (specify) _____________ WS.9 If water and soap, do you have a special place you put the soap for hand washing? I = Yes 2= No SECTION 4: WASH CARE GROUP MEETINGS CG.1 Have you been to a Care Group meeting on Water, Sanitation, and Hygiene? I = Yes 2= No If No, skip to CG.5 CG.2 How long ago was this meeting? I = Within the past month 2= Within the past two months 3= Within the past three months 4= Three or more months ago 5= I do not remember CG.3 How effective do you feel the meeting was in teaching about Water, Sanitation, and Hygiene? I = Very effective 2= Somewhat effective 3= Not very effective 4= I do not remember CG.4 What topics were discussed at the Care Group meeting on Water, Sanitation, and Hygiene? You can choose more than one option I = Critical hand washing moments 2= Causes of diarrhea 3= Symptoms of diarrhea 4= Treatment of diarrhea 5= Hand washing with soap 6= Disposal of 7= All of the above 8= None of the above 9= Other (specify) ______________ CG.5 Are there any topics that were not covered that you would like to learn about Water, Sanitation, Hygiene? I = Yes (specify) _________________ 2= No CG.6 How i mportant do you feel learning about Water, Sanitation, and Hygiene is for you and your baby? I= Very important 2= Somewhat important 3= Not very Important 4= I do not wish to answer

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PAGE 74 SECTION 5: Appreciative Inquiry AI.I What attracted you to want to join your Care Group? AI.2 What do you hope your Care Group family will accomplish within your community? AI.3 What aspects of your Care Group family are the most effective in sharing maternal and child health information? What other health information do you feel could increase this effectiveness? AI.4 What recommendations do you have for CFK to allow for the continued effectiveness of your Care Group family? END. THANK THE RESPONDENT AND CONCLUDE THE SESSION.



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Form online: http://digital.uflib.ufl.edu/procedures/copyright/GrantofPermissions.doc GRANT OF PERMISSIONS In reference to the following title(s): Velez, Rachel Fostering the Capacity of Kibera's Care Groups to Promote WASH Behaviors Among Pregnant and Lactating Women. Gainesville, FL; University of Florida, 2017. I, ____ Rachel Velez ___, a s copyright holder or licensee with the authority to grant copyright permissions for the aforementioned title(s), hereby authorize the University of Florida, acting on behalf of the Board of Trustees of the University of Florida to digitize, distribute a nd archive the title(s) for nonprofit, educational purposes via the Internet or successive technologies. This is a non exclusive grant of permissions for on line and off line use for an indefinite term. Off line uses shall be consistent either, for educat ional uses, with the terms of U.S. copyright legislation's "fair use" provisions or, by the University of Florida, with the maintenance and preservation of an archival copy. Digitization allows the University of Florida to generate image and text based ve rsions as appropriate and to provide and enhance access using search software. This grant of permissions prohibits use of the digitized versions for commercial use or profit. _________ ________________________ Signature of Copyright Holder _____ Rachel Velez ______________ ___ Printed or Typed Name of Copyright Holder _____ 4/26/17 ___ Date of Signature Attention : Digital Services / Digital Library Center Smathers Libraries University of Florida P.O. Box 11700 3 Gainesville, FL32611 700 3 P: 352.273.2900 DLC@uflib.ufl.edu