AN INVESTIGATION OF THE SPATIAL VARIATION OF DIARRHEAL

INCIDENCES AMONG CHILDREN AGED LESS THAN FIVE YEARS: A

CASE STUDY OF KERICHO WEST SUB-COUNTY, KERICHO COUNTY

JOAB KIBALIACH

A Research Proposal submitted to the School of Humanities and Social Sciences

in partial fulfillment for the requirements of the award of the Master of Arts in
Geography Degree of Mount Kenya University.

MARCH 2015

DECLARATION

Declaration by Student
This Research Proposal is my original work and it has not been presented for a degree or any
other award in this or any other university/institution.

Signature --------------------------------------

Date ------------------------------------

Japhet Kipngeno
MAGE/2013/46745

Declaration by Supervisor
This Research Project Report has been submitted for examination with our approval as a
University Supervisor
Signature ----------------------------------------------

Date---------------------------------------

University Supervisor
Prof. Kennedy .N. Ondimo

Signature ---------------------------------------------University Supervisor

Dr. Were George Eshiamwata

ii

Date---------------------------------------

ABSTRACT
Acute diarrheal disease among children younger than five years old remains a major cause of
morbidity and mortality worldwide. Severe infectious diarrhea in children occurs most
frequently under circumstances of poor environmental sanitation and hygiene, inadequate
water supplies, and poverty. This is the major challenge if the millennium development Goals
and sustainable Development is to be achieved. In Kenya, the control of diarrhea disease,
including promotion of breast feeding, oral rehydration therapy and specific health education
is a part of national strategies aiming to improve the quality of life and reduce the burdens
caused by diseases. Despite this fact, diarrheal disease is still the third leading cause of
infectious morbidity and mortality in children as well as in adults in Kenya. The local
epidemiology of diarrhea in most rural areas of Kenya has not been researched thoroughly. In
addition, most studies in Kenya have focused on a specific pathogen rather than identifying
the most common pathogens of diarrhea among children in rural areas. Better understanding
of the local epidemiology of diarrhea disease and the spatial variation of the same, could be a
valuable contribution to the development of public health prevention. The main objective of
the study is to investigate the spatial variation of the diarrheal incidences among children
aged less than five years at Kericho County on both an urban and a rural setting. The study
will be carried out using structured questionnaire. The location of the study will be in Kericho
West sub-county. Sample population will picked from households for the study to determine
the spatial variation of diarrheal incidence in children at Kericho West sub-county. The
sample will be picked from urban centers and a rural setting. Data collection for the study
will begin with delivering questionnaires to the household heads by the researcher.
Questionnaires and interview guide are the instruments that will be used in the study. After
data collection, editing, coding of similar themes, classifying and tabulating are the
processing steps that will be used to process the collected data for a better and efficient
analysis. After the analysis, findings will be drawn, recommendations made and suggestions
for further research given.

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TABLE OF CONTENTS
DECLARATION......................................................................................................................ii
ABSTRACT .............................................................................................................................iii
TABLE OF CONTENTS ....................................................................................................... iv
ABBREVIATIONS AND ACRONYMS ..............................................................................vii
CHAPTER ONE: ..................................................................................................................... 1
INTRODUCTION.................................................................................................................... 1
1.1 Background of the Study ..................................................................................................... 1
1.2 Statement of the Problem ..................................................................................................... 2
1.3 Objectives of the study......................................................................................................... 2
1.3.1 Broad Objective ................................................................................................................ 2
1.3.2 Specific objectives ............................................................................................................ 3
1.4 Research questions ............................................................................................................. 3
1.5 Significance of the Study ..................................................................................................... 3
1.6 Scope of the Study ............................................................................................................... 3
1.7 Justification of the study ...................................................................................................... 4
1.8 Assumption of the Study ...................................................................................................... 4
1.9 Operational definition of key variables................................................................................ 4
CHAPTER TWO ..................................................................................................................... 6
LITERATURE REVIEW ....................................................................................................... 6
2.1 Overview of diarrheal diseases ............................................................................................ 6
2.2 Causes of diarrheal Diseases ................................................................................................ 6
2.3. Impacts of diarrheal diseases on sustainability development and economic growth .......... 7
2.3.1 Diarrheal diseases and water supply and sanitation .......................................................... 8
2.3.2 Diarrheal diseases and socioeconomic status ................................................................... 9
2.3.3 Demographic factors: ........................................................................................................ 9
2.3.4 Breastfeeding/ Eating habits ........................................................................................... 10
2.3.5 Hygiene practices: ........................................................................................................... 10
2.4.0. Millennium Development Goals .................................................................................... 10
2.5.0 Prevention measures and treatment package by World Health Organization and
Government of Kenya .............................................................................................................. 11
2.6 Theoretical Models ............................................................................................................ 12
2.7 Geo additive model ............................................................................................................ 13
2.8 Empirical Review............................................................................................................... 13
iv

2.9 Microbiology of diarrheal disease ..................................................................................... 14

2.10 Relationship between microbial indicators and pathogens .............................................. 15
2.11.Theoretical framework ..................................................................................................... 16
2.12 Conceptual Framework .................................................................................................... 16
CHAPTER THREE ............................................................................................................... 17
RESEARCH DESIGN AND METHODOLOGY ............................................................... 17
3.1.0 Introduction ..................................................................................................................... 17
3.2.0 Study Area ...................................................................................................................... 17
3.2.1 Geographical location ..................................................................................................... 17
3.2.2 Climate of Kericho West ................................................................................................ 17
3.3 Target Population ............................................................................................................... 18
3.4 Description of Sampling Procedure and Sample Size ....................................................... 19
3.5 Sample size ........................................................................................................................ 19
3.6 Data Collection Instruments and Procedures ..................................................................... 20
3.6.1 Questionnaire .................................................................................................................. 20
3.6.2 Interviews ........................................................................................................................ 20
3.7 Piloting of Instruments ....................................................................................................... 20
3.8 Validity .............................................................................................................................. 21
3.9 Reliability ........................................................................................................................... 21
3.10 Data Collection Procedure ............................................................................................... 22
3.11 Data Analysis Procedure .................................................................................................. 23
3.12 Ethical Issues ................................................................................................................... 24
3.13 Research Gap ................................................................................................................... 24
3.14 Output .............................................................................................................................. 25
REFERENCES ....................................................................................................................... 26
APPENDICES ........................................................................................................................ 29
Appendix I: Questionnaires .................................................................................................... 29
Appendix II: Questionnaires .................................................................................................... 30
Appendix III: Study Timeframe.............................................................................................. 36
Appendix IV: Study Budget..................................................................................................... 37

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ABBREVIATIONS AND ACRONYMS

ORS

Oral rehydration salts

UNICEF

United Nations International Childrens Emergency

WHO

World Health Organization

CDD

Control of diarrheal diseases

CI

Confidence interval

DALYs

Disability adjusted life years

DHS

Demographic and Health Survey

MDGS

Millennium Development Goals

Fund

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CHAPTER ONE:
INTRODUCTION

1.1 Background of the Study

Diseases are major challenge to sustainable development .According to the World Health
Organization (WHO,2009) and( UNICEF, 2010) there are about two billion cases of diarrheal
disease worldwide every year, and 1.9 million children younger than 5 years of age perish
from diarrhea each year, mostly in developing countries. This amounts to 18% of all the
deaths of children under the age of five and means that more than 5000 children are dying
every day as a result of diarrheal diseases. Of all child deaths from diarrhea, 78% occur in the
African and South-East Asian regions.
UNs Millennium Development Goals Report 2010, evaluates progress thus far, cites
diarrheal disease control as a critical priority for achieving reduction by two-thirds the underfive mortality rate and notes the low-cost prevention and treatment tools available today to
realize dramatic reductions in child mortality. Better hygiene and access to drinking water
and sanitation will accelerate progress toward two MDGs: Reduce under-Five child
mortality rate by 2/3 between 1990 and 2015and By 2015 halve the proportion of people
without sustainable access to safe drinking water and basic sanitation. Meeting the latter
goal will require infrastructure investments of about US$23 billion per year, to improve water
services for 1.5 billion more people (292,000 people per day) and access to safe sanitation for
2.2Billion additional people (397,000 per day). Fewer than one in five countries are on track
for meeting this target. The United Nations (UN) has set the Millennium Development Goals
(MDGS) for all countries worldwide to reduce the rate of infant mortality in under-5s by twothirds between 1990 and 2015.

Diarrheal disease remains a leading cause of mortality and morbidity of children in SubSaharan Africa, a region where unique geographic, economic, political, socio cultural, and
personal factors interact to create distinctive continuing challenges to its prevention and
control. Whereas childhood mortality rates from diarrhea are expected to decrease by 30 to
50% in most areas of the world between 1990 and 2000, the decline in Sub-Saharan Africa is
estimated to be only 3%. Consequently, approximately 40% of childhood deaths from
diarrhea worldwide will occur in Sub-Saharan Africa by the year 2000, although only 19% of
the worlds population under the age of five years will live in this region. This continuing

epidemic deserves sustained programmatic and research attention as international public

health moves on to confront newer issues in infectious disease and the changing burdens of
disease associated with the demographic transition

The primary causes of many childhood illnesses in Kenya are water and sanitation-related.
Amongst these illnesses, diarrhea remains one of the most important environmental health
problems. Diarrheal diseases cause 16 % of deaths among children below five years in Kenya
and are second only to pneumonia as a cause of deaths in this cohort (GOK, 2010). Millions
of dollars are spent on treatment of diarrhea annually. According to (GOK, 2010), in most
rural public health facilities diarrhea is ranked number three of the leading causes of
outpatient attendance. About 80% of hospital attendance in the country is due to preventable
diseases and 50% of these diseases are water, sanitation and hygiene related (GOK, 2007).
.
1.2 Statement of the Problem
Population surveys of health and fertility provide valuable insights into the etiology of
diseases in developing countries. Moreover, they can provide nationally and regionally
representative estimates on a range of epidemiologic variables. The Demographic and Health
Surveys (DHS) are a well-established source of reliable population data with a substantial
focus on childhood diseases and health-seeking behavior. However, linking individual survey
records with disease prevalence at the disaggregated small-scale, community level has not
been possible because of the traditional methodology used. It is critical for policy makers to
understand the prevalence of these diseases to plan proper health-care interventions at a
community level.
In previous analyses, examination of spatial location and childhood diseases for the Kenyan
Demographic health Survey has been done; in this study, the researcher investigates spatial
variation in diarrheal incidences among children in Kericho West sub-county.
1.3 Objectives of the study
1.3.1 Broad Objective
The main objective of this study is to reduce infant mortalities arising from water diseases in
Kenya through increased knowledge of spatial variation.

1.3.2 Specific objectives

i.

To assess the spatial patterns and temporal trends of diarrheal disease in Kericho
West sub-county

ii.

To investigate socio-economic factors that influence diarrheal diseases in children

at Kericho west sub-county

iii.

To investigate the safety of water, sanitation and hygiene in Kericho West SubCounty

1.4 Research questions

i.

What are spatial patterns and temporal trends of diarrheal diseases in Kericho
west sub-county?

ii.

How does socio-economic status influence diarrheal diseases in children at

Kericho west sub-county?

iii.

What is the relationship between diarrheal diseases and safety of water,

sanitation and hygiene in Kericho west sub-county?

1.5 Significance of the Study

At a local level, the local community will find the results useful. The study findings will be
used by the community in adopting best practices geared towards addressing the root causes
of diarrheal diseases in the community. The study anticipates helping policy makers to
understand the prevalence of these diseases to plan proper health-care interventions at
community level. The results can be applied by health care providers at local level, county
level and national levels in planning and executing health care services and formulating
policies that address diseases associated with poor hygiene. These policies can contribute
toward s achieving the Millennium Development Goals in Sub-Saharan Africa where
mortality seems to be high.

1.6 Scope of the Study

The study will only focus on the spatial variation of the diarrheal incidences on children age
less than five years within Kericho west sub-county, Kericho County. Even though there may
be many diseases in the study area, this study will only focus on diarrheal diseases.

1.7 Justification of the study

Diarrhea is still one of the leading causes of childhood mortality in developing countries.
Each year, approximately 1.5 million children die from diarrheal diseases globally (WHO,
2010) and (UNICEF, 2009). Diarrhea is characterized by the increase of fluidity and
frequency of fecal evacuation (Black 1982) and results from a variety of infectious
microorganisms, including bacteria (e.g. Shebelle), viruses (e.g. rotavirus and adenovirus),
protozoa (Cryptosporidium) and helminthes (Albert et al. 1999; Denney., 2005; Guaranty et
al. 1990; Kusch et al. 2006). Enterotoxigenic, E. coli and rotaviruses are the most common
diarrheal pathogens in developing areas. In developed countries, Norwalk-like viruses,
Campylobacter, jejuna and Clostridium difficult are common pathogens causing diarrheal
diseases (Guaranty et al. 1990).
Diarrheal diseases are a major public health problem in Kenya. Understanding the spatial
patterns and temporal trends of diarrheal diseases is important in order to develop appropriate
interventions and control measures. Geographic information systems (GIS) and spatial
statistics are applied to identify spatial clusters or space-time clusters of three types of
diarrheal diseases in Kericho West County. With the above in mind this study seeks to
investigate spatial variation of diarrheal incidences among children below five years at
Kericho West Sub-County.
1.8 Assumption of the Study
The study assumes that the respondents will be able to give honest and sincere responses to
all items in the questionnaire. It also assumes that Diarrheal disease is rampant within
Kericho west sub-county.

1.9 Operational definition of key variables

Socioeconomic Status (SES)
SES affects diarrheal diseases in many ways. First, people with low SES have less of a
change to access improved water supply, sanitation and hygiene. Second, people with low
SES often have poor nutrition and education. In addition, people with low SES have a greater
chance of living in poor environmental conditions and less access to health care

Commented [A1]: Include in reference section

Breastfeeding
In general, the morbidity of diarrhea is lowest in exclusively breast-fed children; it is higher
in partially breast-fed children, and highest in fully-weaned-children.

Hygiene practices
This refers to children not washing hand before meals or after defecation and mothers not
washing hands before feeding children or preparing foods.

Demographic factors
The prevalence is highest for children 6-11 months of age, remain at a high level among the
one year old children, and decrease in the third and fourth years of life. Higher rate of
diarrhea has been observed in boys than girls

Water supply and Sanitation

Well-designed projects combining water supply and sanitation education might reduce
diarrhea morbidity rate by 35-50%. It is widely believed that poor water quality is one of the
major factors related to diarrheal disease

CHAPTER TWO
LITERATURE REVIEW
2.1 Overview of diarrheal diseases
The chapter explores the literature that focuses on the area of spatial variation of diarrheal
incidences of children. The chapter commences by reviewing the theories that inform the
discussion on spatial variation of diarrheal incidence on children. It examines the background
to the study, problem statement, objectives of the study, research questions, significance of
the study, scope of the study, limitation of theoretical framework and conceptual framework
adopted for this study.

2.2 Causes of diarrheal Diseases

The main causes of diarrheal diseases are poor hygienic, poor sanitation access to water and
by infectious pathogens (Gracey, 1985)

Bacterial infections, Diarrhea caused by enteric bacterial infections is very important

worldwide, especially in tropical and developing countries, and is a serious problem among
older children and adults as well as in infants and young children. The range of causative
microorganisms is very large; they include E. coli, Salmonella, Shigella, Campylobacter,
Yersinia, vibrios, and Clostridium difficile (Gracey M, 1996)
Viral infections: Rotavirus is one of the most common causes of severe diarrhea. Other
viruses may be important causes of diarrheal disease in human, including Norwalk virus,
Norwalk-like viruses, enteric adenoviruses, caliciviruses, and astroviruses (Gracey M, 1996)

Parasites, Parasites can enter the body through food or water and settle in the digestive
system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica,
Cyclospora cayetanensis and Cryptosporidium.Food intolerances, some people are unable to
digest some component of food, such as lactose - the sugar found in milk, or gluten found in
wheat and barley.
Reaction to medicines, some kinds of antibiotics (such as clindamycin, cephalosporins, and
sulfonamide.), laxatives and antacids.Intestinal diseases like inflammatory bowel disease or
celiac disease.Functional bowel disorders, such as irritable bowel syndrome, in which the
intestines do not work normally.
Types of diarrheal disease: Acute water diarrheal, dysentery, persistent diarrheal and chronic
diarrhea Risk factors of diarrheal disease Demographic factors, socioeconomic factors, water
6

related factors, sanitation, hygiene practices, breastfeeding, malnutrition, immunodeficiency,

seasonal distribution, consumption of foods sold by the street vendors and eating habits
Diarrheal diseases kill approximately 2 million people annually, yet the majority of death can
be prevented through environmental interventions (Pruss-Ustum and Corvalan 2007).
Globally, more than 1.1 billion people do not have access to safe drinking water and 2.6
billion individuals do not have improved sanitation facilities (WHO and UNCIEF 2004). The
lack of access to improved water and sanitation is clearly linked to the number of deaths
attributable to diarrheal diseases (Montgomery and Elimelech, 2007).
Eating with the dirty hands; eating raw foods; using unboiled water, may increase the risk
of diarrhea.

2.3. Impacts of diarrheal diseases on sustainability development and economic growth

Diarrhea remains the second leading cause of the mortality of children under five, which kills
approximately 1.5 million children and causes 2 billion people to become sick each year
globally (UNICEF and WHO 2009). Diarrhea is characterized by the increase of fluidity and
frequency of fecal evacuation (Black, 1984) and in this study is defined as the passing of 3
or more watery or loose stools during 24 hours period (UNCIEF and WHO 2009). According
to the symptoms of patients, diarrhea is grouped into three major types. One is called acute
watery diarrhea, which causes different degrees of dehydration. Another is called bloody
diarrhea, which results in dysentery and is characterized by bloody stool. The third is
persistent diarrhea, which commonly lasts more than two weeks (Keusch et al., 2006).

The causes of diarrheal disease include bacteria, viruses, protozoa and helminthes. The
disease is primarily transmitted through the fecal-oral route, which involves the transmission
of pathogens through the environment to human host. An F-diagram drawn by Wagner and
Lanoix (1958) summarized the potential routes of the transmission. Briefly, pathogens shed
in feces may get into fluids, foods and on fingers and fomites, some may directly infect hosts.
Flies touched with feces can carry pathogens to food or surfaces or directly transmit to hosts.
Any measure that blocks the transmission routes demonstrated in the F-diagram have
potentials to prevent disease transmission. For this reason, WHO (2009) recommended that in
order to prevent diarrheal disease one must focus on the following: water, sanitation and
hygiene; adequate nutrition; breastfeeding; micronutrients supplements and immunization.

2.3.1 Diarrheal diseases and water supply and sanitation

The lack of access to improved water and sanitation is clearly linked to the number of deaths
attributable to diarrheal diseases (Montgomery and Elimelech 2007).Diarrheal diseases kill
approximately 2 million people annually, yet the majority of death can be prevented through
environmental interventions (Pruss-Ustum and Corvalan 2007). Globally, more than 1.1
billion people do not have access to safe drinking water and 2.6 billion individuals do not
have improved sanitation facilities (WHO and UNCIEF 2004).

A number of studies have suggested that interventions to improve water supply, sanitation
and hygiene are beneficial to the prevention and control of diarrheal diseases

(Cain cross et

al, 2010). An early review of the effectiveness of water supply and excreta disposal
improvement was written by Esrey et al, (1985). Their results suggested that well-designed
projects combining water supply, sanitation and hygiene education might reduce diarrhea
morbidity rate by 35-50%. Through a systematic review and meta-analysis, found that water;
sanitation and hygiene interventions had similar effects on the reduction of diarrhea disease
in developing countries, with the relative risk estimation ranging 0.63 to 0.75. The results
from a recent study (Cairn cross et al, 2010) suggested hand washing with soap; improved
water quality and excreta disposal could reduce the risk of diarrhea by 48%, 17% and 36%,
respectively.

It is widely believed that poor water quality is one of the major factors related to diarrheal
disease. However, studies have also found that improving the quantity of water available
might be more effective at reducing transmission of diarrheal diseases than ensuring better
water quality in developing countries (Cairncross 1990).

In general, adequate water supply encourages and facilitates better hygiene behaviors, in
particular, frequent hand washing. This assumption was supported by findings from
Nicaragua, where children with poor water access had a 34% higher rate of diarrhea than
children with good water accessibility (Gorter et al., 1991). Similarly, safe excreta disposal is
also a primary barrier to disease transmission. Four studies documented in China showed that
safe stool disposal could reduce diarrhea morbidity by 63%, 51%, 20% and 8%, respectively
(Cairncross et al., 2010). A case control study in Burkina Faso reported that risk of diarrhea
among children under 3 without safe stool disposal was 50% higher than children using
latrine (Teaore1941).
8

2.3.2 Diarrheal diseases and socioeconomic status

Though diarrheal diseases have similarly adverse effects on rich and poor, young and old,
developing countries and developed countries, its prevalence and health impacts are clearly
associated with socioeconomic status. The concept of SES is pervasive, which refers to the
position of individuals, families, households, or other aggregates on one or more dimensions
of stratification. These dimensions include income, education, prestige, wealth, or other
aspects of standing that members of society deem salient (Bollen et al., 2001). The inverse
relationship between SES and diarrhea has been illustrated in many studies. For example,
D'Souza and Bhuiya (1982) assessed the SES of each household in the Matlab area using the
following indicators: year of education of the head of household or mother, occupation, size
of dwelling, ownership of cow and health practice. They found that the low SES groups had
higher mortality rates from diarrheal diseases whenever these indicators were included in
analyses.

A study in Brazil found that the number of diarrhea cases among children with low SES were
two times higher than that among children with high Socioeconomic status, though both
groups lived in a similar urban environment (Seigel 1996). Emch (2010) found that SES had
a significant impact on cholera occurrence in Bangladesh, namely, households with a higher
score had a lower rate of cholera occurrence.

Socio-Economic Status affects diarrheal diseases in many ways. First, people with low SES
have less of a change to access improved water supply, sanitation and hygiene. Second,
people with low Socio-Economic Status often have poor nutrition and education. In addition,
people with low Socio-Economic Status have a greater chance of living in poor
environmental conditions and less access to health care. All of these factors lead to a higher
incidence of diarrheal disease among people with low Socio Economic Status.

2.3.3 Demographic factors:

Many studies have established that the diarrhea prevalence is higher in younger children
(Woldemicael G, 2001). The prevalence is highest for children 6-11 months of age, remain at
a high level among the one year old children, and decrease in the third and fourth years of life
(Marjatta, 1994). Higher rate of diarrhea has been observed in boys than girls (Molbak et al.,
1997). Other demographic factors, like mothers younger age (Marjatta, 1994), low level of
9

mother's education, high number of siblings (Woldemicael G, 2001), birth order, were
significantly associated with more diarrhea occurrence in children less than five.

2.3.4 Breastfeeding/ Eating habits

Eating with the hands; eating raw foods; or drinking unboiled water, may increase the risk of
diarrhea
The literature on feeding practices and risk of diarrhea is extensive. In general, the morbidity
of diarrhea is lowest in exclusively breast-fed children; it is higher in partially breast-fed
children, and highest in fully-weaned-children (Molbak, 2000). In addition, a particular risk
of diarrhea is associated with bottle-feeding .Many studies have shown the strong protective
effect of breast feeding. A high concentration of specific antibodies, cells, and other
mediators in breast milk reduces the risk of diarrhea following colonization with entero
pathogens (Molbak K, 2000).

2.3.5 Hygiene practices:

Some studies have revealed that children not washing hand before meals or after defecation
(Gorter et al., 1998) mothers not washing hands before feeding children or preparing foods
(Marjatta, 1994), children eating with their hands rather than with spoons (Aulia et al., 1994)
eating of cold leftovers . (Molbak et. al., 1997) dirty feeding bottles and utensils (Curtis,
2000) unhygienic domestic places (kitchen, living room, yard) (Woldemicael, 2001), unsafe
food storage (Curtis, 2000), presence of animals inside the house (Molbak et al., 1997)
presence of flies inside the house (Curtis, 2000), were associated with risk of diarrhea
morbidity in children.

Good personal hygiene behaviors, particularly, hand washing, can block multiple
transmission routes. A number of epidemiological studies have demonstrated that hand
washing remarkably reduced the morbidity of diarrhea in developing countries (Wilson et al.,
1991; Hoque et al., 1986; Pinfold et al., 1996; Peterson et al., 1998). For example, a study in
Thailand found that the promotion of hand washing and dish washing led to a substantial
reduction of hand contamination and diarrheal diseases (Pinfold et al., 1996).

2.4.0. Millennium Development Goals

MDG1. Eradicate extreme poverty and hunger.
MDG2. Achieve universal primary education
10

MDG3. Promote gender equality and Empower women

MDG 4. Reduce by two two-thirds the under five mortality rate
MDG 5. Improve maternal health
MDG 6. Combat HIV/Aids, Malaria and other diseases
MDG 7. Ensure Environmental Sustainability
MDG 8. Develope a Global partnership for development

2.5.0 Prevention measures and treatment package by World Health Organization and
Government of Kenya
The treatment package focuses on two main elements, as laid out in the (UNICEF and WHO
2004) joint statement. Fluid replacement to prevent dehydration and Zinc treatment
Oral rehydration therapy is the cornerstone of fluid replacement. New elements of this
approach include low-osmolality ORS, which are more effective at replacing fluids than the
previous ORS formulation, and zinc treatment, which decreases diarrhea severity and
duration. Important additional components of the package are continued feeding, including
breastfeeding, during the diarrhea episode and use of appropriate fluids available in the home
if ORS are not available

The prevention package focuses on five main elements to reduce diarrhea in the medium to
long term: Rotavirus and measles vaccinations, Promotion of early and exclusive
breastfeeding and vitamin A supplementation, Promotion of hand washing with soap,
improved water supply quantity and quality, including treatment and safe storage of drinking
household water and Community-wide sanitation promotion.

New aspects of this approach include rotavirus vaccination, which was recently
recommended for global introduction .In terms of community-wide sanitation, new
approaches to increase demand to stop open defecation have proven more effective than
previous strategies. However hand washing with

soap after visiting toilet,before

eating,before cooking and after changing your child nappies(UNICEF 2014).

11

2.6 Theoretical Models

Spatially explicit models of Cholera Epidemics
The prevention of pandemics requires a better knowledge of the disease diffusion pattern. A
better understanding of the transmission of cholera underlies the development of accurate
mathematical models, which may be used in evaluation of possible scenarios. The first
mathematical model developed by Capasso in 1979 (Torres, 2001) proposed only the
dynamics of an infected population within a community together with an aquatic population
of bacteria.

This model was improved in 2001 (Torres, 2001), by including a third differential equation
modeling: concentration of pathogen V. Cholerae in a water source, susceptible and infected
individuals. With these three equations the emergence of cholera was analyzed and three
possible outcomes were identified: (1) No outbreak, (2) an epidemic peak followed by
extinction of the disease, and (3) an epidemic peak followed by subsequent outbreaks
seasonally persisting. The numerical simulations exhibited a good fit with the actual cholera
mortality data, but only for locations where a unique epidemic peak was present during the
year.
A third mathematical model was proposed by Pascual et al. (2002) adding a fourth equation.
The variables under consideration were: number of susceptible individuals, infected
individuals, bacteria abundance and water volume. The model hence, was able to capture the
seasonality showed by cholera in several endemic zones. Furthermore, they have found that
the basic reproductive number that quantifies the number of new infections produced in a
population of susceptible individuals by the first infected host individual was sensitive to
environmental variables that can vary not only during the year but also over long time scales.

These findings envisioned a potential dual role of rainfall. On the one hand, short wet seasons
favor environmental conditions for cholera leading to outbreaks. On the other hand, long wet
seasons create a dilution effect avoiding the settlement of the bacterium in the environment,
although outbreaks might still occur due to human aggregation. Analysis based on point
pattern analysis techniques, considering cholera and rainfall time series from 1900 to 1940 in
the Madras Presidency region agree with this double role of rainfall (Ruiz-Moreno et al.,
2005).

12

2.7 Geo additive model

Specifically, the researcher applies the generalized geo additive model as an alternative to the
common linear model, in the context of analyzing childhood disease in developing countries.
This will enable the researcher to account for nonlinear, location effects on childhood
morbidity at the county level and to assess temporal and geographical variation in while
simultaneously controlling for important risk factors.
2.8 Empirical Review
Of the estimated total 10.6 million deaths among children younger than five years of age
worldwide, 42 percent occur in the World Health Organization (WHO) African region (Bryce
et al., 2005). Although mortality rates among these children have declined globally from 146
per 1,000 in 1970 to 79 per 1,000 in 2003 (WHO, 2005), the situation in Africa is strikingly
different. As compared with other regions of the world, the African region shows the smallest
reductions in mortality rates and the most marked slowing down trend. The under-five
mortality rate in the African region is seven times higher than that in the European region. In
1980 this difference was equal to 4.3 times (WHO, 2005).
During the 1990s, the decline of under-five mortality rates in 29 countries of the world
stagnated, and in 14 countries rates went down but then increased again. Most of these
countries are from the African region (WHO, 2005). A factor that may contribute to this
situation is the human immunodeficiency virus/acquired immune deficiency syndrome
(HIV/AIDS) epidemic in the region, but an underlying weakness of the implementation
capacity of the health system is also likely to blame (Walker, Schwartlnder, and Bryce
2002).
Similarly to all-cause mortality, global estimates of the number of deaths due to diarrhea have
shown a steady decline, from 4.6 million in the 1980s (Snyder and Merson 1982) to 3.3
million in the 1990s (Bern, 1992) to 2.5 million in the year 2000 (Kosek, et al., 2003).
However, diarrheal diseases continue to be an important cause of morbidity and mortality
worldwide, and despite all advances in health technology, improved management, and
increased use of oral rehydration therapy (ORT) in the past decades; they remain among the
five major killers of children under five years of age.

13

In contrast to mortality trends, morbidity due to diarrhea has not shown a parallel decline, and
global estimates remain between two and three episodes of diarrhea per child under five per
year. Kosek, (2003) estimated a global median incidence of diarrhea to be 3.2 episodes per
child-year in the year 2000, similar to those found in previous reviews by Snyder and Merson
(1982) and by Bern (1992) as well as to those reported in the first edition of Disease Control
Priorities in Developing Countries (Jamison et al. 1993).
2.9 Microbiology of diarrheal disease
Diarrheal disease is caused by a variety of infectious microorganisms, including bacteria (e.g.
enterotoxigenic E. coli, Shigella, Vibrio cholera and Salmonella), viruses (e.g. rotavirus,
norovirus and adenovirus), protozoa (Cryptosporidium, Giardia) and helminthes (Keusch et
al, 2006; Guerrant et al., 1990; Albert et al, 1999; Dennehy 2005). Enterotoxigenic E. coli
and rotaviruses are two of the most frequent pathogens in developing areas. In developed
countries, Norwalk-like viruses, Carmpay lobacter jejuni and Clostridium difficile are
common pathogens causing diarrheal diseases (Guerrant et al., 1990).
The genus of Shigella is composed of four species: S. dysenteriae, S. flexneri, S. boydii and S.
sonnei. S. dysenteriae and S. flexneriare two species commonly found in developing areas,
while S. sonnei is the most common in developed countries. Shigella can lead to bloody
diarrhea, and most patients are children under 5. Improvement of water sanitation and
hygiene can greatly reduce the infection rate (Stoll et al, 1982; Keusch et al, 1989). Vibrio
cholera is an etiological bacterium of cholera, which causes watery diarrhea and is prevalent
in South Asia. Two main infectious serotypes are V. cholerae and V. cholerae 139. Vibrio
cholerae is more frequently found in patients stool samples in rural Bangladesh, and there is
seasonal variation (Sash et al., 2003). The spatial and temporal pattern of cholera is clearly
different from that of no cholera watery diarrhea in rural Bangladesh (Emch and Ali 2001).

Rotavirus is a common viral pathogen responsible for childhood diarrhea. Rotavirus is a

double-stranded RNA virus and has seven serotypes. Three serotypes (A, B and C) are
infectious for humans and serotype A is responsible for 90% of infections in human.
Rotavirus can cause diarrhea disease in all age groups but most commonly infects infants and
young children. A two-year study of rotavirus-associated diarrhea in rural Bangladesh found
that rotavirus was detected in 46.5% of stool samples of patients age 7 months to 12 months
(Fun et al, 1991). Improvement of water and sanitation has not had much influence on the

14

Commented [A2]: Include in reference section

Commented [A3]: Not in reference section. Please include

reduction of rotavirus-associated diarrhea. Reducing the prevalence of diarrhea and death

caused by rotavirus primarily depends on vaccination of infants (Dennehy 2007).

Recently, nor viruses are recognized as a leading etiological agent of diarrheal disease in both
developing and developed areas and affect people of all ages (Chapin et al., 2005; Dey et al.,
2007; Phan et al., 2004; Vilchez et al., 2009). NoVs, previously called as Norwalk-like
viruses, are single stranded RNA viruses, which belong to the Caliciviridae family (Zheng et
al., 2006). NoVs are classified into 5 genotypes and genotype I and genotype II are more
frequently related to human diseases (Zheng et al., 2006). NoVs are highly contagious and
can cause diseases with a few viral particles (Patel et al., 2009). Diarrhea caused by Novas
can be transmitted directly through person to person contact or through Nova- contaminated
surfaces, water and food (Teunis et al., 2008).

Prevention and control of NoVs-associated diarrhea mainly depends on measures that prevent
people from being exposed to contaminated water and foods, strict personal hygiene and the
disinfection of environmental surfaces (Patel et al., 2009).
Adenovirus is another common viral pathogen that causes diarrheal disease in both developed
and developing countries. Human adenoviruses are ubiquitously found in human feces and
frequently detected in water contaminated by human feces and sewage. They are doublestranded DNA viruses and classified into 6 subgroups and 51 serotypes (Jiang 2006).

2.10 Relationship between microbial indicators and pathogens

Because microbial contamination in water still leads to waterborne diseases outbreaks
(Mackenzie et al, 1994; Hrudey and Hrudey 2004), monitoring pathogens in water is
necessary for the protection of public health. However, it is impractical to monitor pathogens
routinely, although advances in new techniques such as quantitative real time PCR
(polymerase chain reaction) (e.g. Guy et al, 2003) and microarrays (e.g. Maynard et al.,
2005) will allow detection of a large number of pathogens rapidly. Microbial indicators such
as E. coli and enterococci are used to assess the status of fecal contamination and the risk of
waterborne diseases (Yates 2007).
The criteria for an ideal indicator were initially proposed by Bonde (1966). It requires that the
presence of indicators can identify the presence of pathogens in water. In addition, indicators
should be correlated to health risk and have similar fate and transport characteristics to

15

pathogens. An ideal indicator should have a strong correlation with the health hazards
associated with a given type of pollution (Cabelli 1983; Dufour 1984).

The relationship between indicators and pathogens has been investigated in many studies.
There is no assurance that indicators can reliably signal the presence of pathogenic
contamination. C. perfringens, total coliforms and fecal coliforms are likely useful indicators
for all three biotypes of pathogens (bacteria, viruses and protozoan). Comparatively, Fspecific coliphages are better indicators for viral pathogens than total coliforms and fecal
coliforms. However, E. coli and enterococci, two frequently used indicators, have not shown
any greater likelihood of correlating with pathogens than other indicators (Wu et al., 2011).

2.11. Theoretical framework

2.12 Conceptual Framework

Independent Variables

Intervening variables

Dependent

Variable

water supply,

Water sources

sanitation

Latrine facility

Demographic

Hand washing

factors

Food storage

Socioeconomic

Weaning

Factors

practice

Hygiene practices

Household

Breastfeeding

crowding
Measles

(Author, 2014)

16

Childhood
Diarrheal disease

CHAPTER THREE
RESEARCH DESIGN AND METHODOLOGY
3.1.0 Introduction
This section deals with description of the methods that is to be used in conducting the
research. It is divided into the following subsections: Study area, Geographical location,
target population, sampling technique, research instruments, pilot study, validity and
reliability, data collection procedures and data analysis technique.
3.2.0 Study Area
Kericho County has a population of over one million, six constituencies namely Kipkelion
East

Constituency,

Kipkelion

West

Constituency,

Ainamoi

Constituency,

Bureti

Constituency, Belgut Constituency, and Sigowet Soin Constituency which are also referred
to us sub-Counties in the County administration. The county has 30 wards all represented by
various Members of County Assemblies in the County Assembly.

3.2.1 Geographical location

Kericho West borders the following counties; Nandi to the North, Uasin Gishu and Baringo
to the North East, Nakuru to the East and South East, Bomet to the South, Nyamira and
Homa-Bay to the South West, and Kisumu County to the West and North West. Kericho
Town is the administrative capital of the county. Kericho County is a county of Kenya. It has
a population of 752,396 (2009 census) and an area of 2,111 km. Its capital and largest town
is Kericho.

3.2.2 Climate of Kericho West

Climate of the area is cool and wet, it receives heavy and reliable rainfall .The months that
receives heavy rainfall are April and October the Mau Forest in Kericho County is the biggest
water catchment area in Kenya. At a high altitude and virtually daily rains, Kericho is the
Centre of Kenyas largest tea industry. Some of the biggest tea companies including Unilever
Kenya, James Finlay and Williamson Tea are based here. It is also home to the popular
Ketepa brand. Much of the tea is exported, with the UK being the largest market. The Mau
Forest in Kericho is the biggest water catchment area in Kenya. At a high altitude and
virtually daily rains, Kericho is the centre of Kenyas large tea industry. Some of the biggest
tea companies including Unilever Kenya, James Finlay and Williamson Tea are based here. It
is also home to the popular Ketepa brand. Much of the tea is exported, with the UK being the

17

largest market. The district is home to some of the worlds best long distance runners.
Kericho west sub-county is within Kericho County where the study will be undertaken

In this study: Random number of urban and rural zones within the sub-county will be selected
as primary clusters. Random number of villages within urban and rural areas will be selected
as secondary clusters. Ultimately number of households will be selected as sampling unit to
be used in the study from both zones. The primary focus of the research will be interviews to
be administered to households and government hospital facilities. Field survey will provide
opportunities to the researcher to gather and review the available existing secondary data and
documentations from the sub-county health offices. Among the frameworks to be accessed
are development plans, legislative acts and strategy documents, and other related studies
within Kericho West County
3.3 Target Population
Mugenda and Mugenda (1999) describe the target population as the complete of individuals
cases or objects with some common characteristics to which the researcher wants to
generalize the results of the study

According to Borg and Gall (1989) target population is defined as all members of a real or

18

hypothetical set of people, events or objects to which an investigator wishes to generalize the
results of the study. The study will conduct a survey using a set of questionnaires in 240
sampled households (60 from the urban centers and 60 from the rural area) on socio
economic, household composition, income, source of water supply, sanitation, demographic
factors, socioeconomic factors, hygiene practices and breastfeeding, livelihood, and
education at household levels. The heads of each household will be interviewed with an aim
of unearthing the major causes of diarrheal disease. Key respondents in this exercise will
include officials from all the hospital and dispensary facilities located in the sub-county
(study area). Mainly cases of diarrheal handled in the last twelve months will be sought to
show seasonality.
3.4 Description of Sampling Procedure and Sample Size
Koul (1984) defines sampling as the process by which a relatively small number of
individuals, objects or events are selected and analyzed in order to find out something about
the entire population from which it is selected. The study will use random sampling. The
researcher finds this sampling appropriate to select representative samples from the
independent groups of parents, school children, clinical officer and school teachers.
Since these respondents do not have a homogenous living environment, it means that
diarrheal incidence habits by each cadre are bound to vary. Therefore, to get a representative
picture of diarrheal incidences, random sampling of these respondents will be most
appropriate.

3.5 Sample size

It is defined as the method of obtaining a small sample from the target population of interest.
Stratified sampling technique will be used and this will involve dividing the target population
into subgroups in order to give equal representation of all targeted population that includes
households. This method is seen as suitable since the population is divided into subgroups on
organization structure. The nature of problem which is investigated means that it is important
to give respondents an equal chance of representation and this will not happen through
random sampling. The sample size will be 120 households. The study will conduct a survey
using a set of questionnaires in 240 sampled households (60 from the urban centers and 60
from the rural area)

19

3.6 Data Collection Instruments and Procedures

Data collection methods involve operationalizing the research design into instruments of data
collection with a view to collecting data in order to meet the research objectives.
Questionnaires and interview guide are the instruments that will be used in the study. This
study will also require some secondary data from the health facilities to compute the results
from the interveiews.
3.6.1 Questionnaire
According to Chandran (2003), a questionnaire is a series of written questions on a topic
about which the respondents opinions are sought. They are useful in a descriptive study
where there is need to quickly and easily get information from people in a non-threatening
way (Davies, 1997; Patton, 1990). This study will use questionnaires as a principal
instrument for data collection. The questionnaire will have two parts: the first, with closed
questions, which sought to gather demographic information and other statistical data from
respondents which included age, marital status, employment and educational level while the
second, with open questions which sought to establish opinion from the respondents and
gather more of the qualitative information on spatial variation of diarrheal incidence of
children at Kericho County
3.6.2 Interviews
Interviewing, as a research technique, involves the researcher asking questions and,
hopefully, receiving answers from the people being interviewed. It is very widely used in
social research and there are many different types. A commonly used typology distinguishes
among structured, semi-structured and unstructured interviews. (Robson, 2002).
Interviews, as a research instrument, have the benefit of allowing the researcher to follow up
on interesting responses that were not expected (Jackson, 1990). Robson (2002) holds that
semi-structured and unstructured interviews are widely used in flexible, qualitative designs.
Thus, the semi-structured interview in combination with the questionnaire will be used for
this study and it will be conducted among the school children to identify their hygiene habits.
The researcher estimated childrens hygiene frequency during the interview.
3.7 Piloting of Instruments
The researcher used primary source of data. Self-administered questionnaires were used to
collect the data. Questionnaires were used because they provided a high degree of data

20

standardization and adoption of generalized information amongst any population (Chandran,

2003).
Pre -testing of the instruments will be done to determine their validity and reliability. This
will target about 5 identical subjects as those who will be included in the study. The five
questionnaires will assess diarrheal prevalence two weeks before the surveys and background
household information. The sample to be used during the pre testing will not be included in
the main study. A test-retest technique or coefficient of stability method will be used to
estimate the degree to which the same results could be obtained with a repeated measure of
accuracy. Since the two test would be very similar, score obtained by each respondent on the
first and the second test would be quite close (Orodho 2004). Through test re-test procedure
the reliability coefficient for the interview schedule and language test will be estimated at
between 0.76 and 0.82 respectively which will be considered adequate.

3.8 Validity
Cook and Campbell (1979), cited in Colosi (1997), define validity as the best available
approximation to the truth or falsity of a given inference, proposition or conclusion. Validity
is the strength of our conclusions, inferences or propositions. There are four types of validity
commonly examined in social research: conclusion validity, internal validity and external
validity.This means that validity will assist the researcher to determine the degree to which
the items presented in the questionnaire are accurate. This is in agreement with Gall et al
(19096), cited in (Nzuki 2004: 31) who observed that: Content experts help determine
content validity by defining, in precise terms, the domain of the specific content that the text
is assumed to represent and then determine how well that content universe is sampled by the
text items, (Nzuki 2004: 31).

3.9 Reliability
Reliability is the consistency of measurement, or the degree to which an instrument measures
the same subjects. Reliability is the measure of the degree to which a researcher instrument
yields consistent results after repeat trials (Kothari 203)... A measure is considered reliable if
a persons score on the same test given twice is similar. It is important to remember that
reliability is not measured, it is estimated. Orodho (2005) defines reliability as the ability of
the research instrument to measure what it is meant to measure consistently and dependably.

21

Reliability of measurement concerns the degree to which a particular measuring procedure

gives similar results over a number of repeated trials. Reliability of the research instruments
will be determined through testing and re-testing.
3.10 Data Collection Procedure
The study will utilize satellite imageries that will obtained from DRSRS and Regional Centre.
The satellite imageries will be those covering the area of study for the period ranging from
2012 to 2014. The land sat images for the area are available since 1973, have high temporal
resolution, and are easily available and affordable. The images will be processed and
analyzed using GIS software to produce GIS maps that will be used in mapping spatially the
spread of the diarrheal disease in the sub-county for the years 2012 and 2014. These years
were selected based on the land sat images that had been secured covering the entire area of
study.
Since the sampled people are within the county, permission to do researches will be sought
from the County, Education Department and Hospitals who will write an introductory letter
to field education officers authorizing the researcher to conduct this study? Data collection
for the study will begin with delivering questionnaires to the teachers, hospital staff, children
and parents by the researcher. Although the questionnaires will be collected at various
intervals after one week, where possible the investigator will leave the respondents venue
with some completed questionnaires. The interview schedule will be administered to parents
and teachers on weekends at their homes when most of them will be free from heavy
responsibilities, hence available for interviews. Interviews for the teachers and parents will be
done in unstructured manner so that the researcher could be able to collect reliable data.

22

3.11 Data Analysis Procedure

Objective

Data collected

Analysis

i) To assess the spatial patterns

-diarrhea

Descriptive,mean

and temporal trends of diarrheal

-where?

disease in Kericho West sub-

-when?

county.

ii) To investigate socio-economic

Economic activities,

factors that influence diarrheal

Status of people e.g.

diseases in children at Kericho

employed, educated or

west sub-county

illiterate.

iii) To investigate the safety of water,

Households, hospitals and

sanitation and hygiene in Kericho

schools

Descriptive/Hypothesis

Correlation, mean.

West Sub-County

The data was analyzed using both qualitative and quantitative techniques. Qualitative data
was analyzed by giving explanation of information obtained from empirical literature
After data collection, editing, coding of similar themes, classifying and tabulating are the
processing steps that will be used to process the collected data for a better and efficient
analysis. Data editing will examine the collected new data to detect errors and omissions for
correction to ensure accuracy and consistency. Data coding will assign symbols to answers to
classify or categorize responses. Data will be coded and recorded on tally sheet after the
systematic analysis of each individual variable for measuring completeness; occurrence and
clarity because row data collected from the field through primary data are never well
organized for interpretation. Data classification reduces data into homogeneous groups or
attributes for getting meaningful relationships. Tabulation arranged data into concise and
logical order in a procedure referred to as tabulation through columns and rows.

23

The two statistical methods; descriptive and inferential analysis will be applied to measure
and determine the relationship that existed among the collected data. Descriptive analysis
such as percentages, mean, mode and coefficient of correlation will be used to help
understand and interpret variables, distributions size, and relationship. The package (SPSS)
11.0 for windows is efficient, reliable, and able to sort and provide correlations between
variables.

3.12 Ethical Issues

The study will involve the use of children participants; thus, in this research, ethical
considerations are identified and prioritized. Specifically, consent and confidentiality factors
are valued during the entire duration of the study. In order to gain the consent of the
respondents regarding this study, the researcher will show a written letter authority and
explain the details of the research, its objectives, purpose and procedure before involving in
the actual interview or administration of the questionnaires. The privacy of the respondents as
well as the confidentiality of their responses will be prioritized as well. The researcher also
will assure respondents that all data gathered for the study would be protected from
unauthorized access.

3.13 Research Gap

A number of studies have suggested that interventions to improve water supply, sanitation
and hygiene are beneficial to the prevention and control of diarrheal diseases (Esrey et al.,
1985; Fewtrell et al., 2005; Curtis et al., 2000; Caincross et al., 2010). An early review of the
effectiveness of water supply and excreta disposal improvement was written by Esrey et al.
(1985). Many studies have shown the strong protective effect of breast feeding. A high
concentration of specific antibodies, cells, and other mediators in breast milk reduces the risk
of diarrhea following colonization with entero pathogens (Molbak K, 2000). From these
studies,
Investigation on spatial variations of diarrheal incidence has not been studied. Hence this
study seeks to investigate spatial variation of diarrheal disease at Kericho west sub-county

24

3.14 Output
The completion of this research proposal will lead to production of reference materials which
may include:

Thesis

Publication

Seminar paper.

25

REFERENCES
(Albert et al. 1999; Denney., 2005; Guaranty et al. 1990; Kusch et al. 2006). Enterotoxigenic,
E. coli. Causes of cholera and epidemic. First edition

Alam, N., Wojtyniak, B., Henry, J. and Rahaman M.M. (1989). Mothers' personal and
domestic hygiene and diarrhea incidence in young children in rural Bangladesh. Introduction
to Epidemiol. 1997; 146(3):273-82. and socio-economic determinants.

Bertuzzo, E., Gatto M., A. Maritan, S. Azaele, I. Rodriguez-Iturbe, and A. Rinaldo (2008),
On the
spacetime evolution of a cholera epidemic, Water Resour. Res., Evaluation of
IMCI Study Group(2003). "Reducing Child Mortality: Can Public Health Deliver?vol .1

Gatto,M., L. Mari, E. Bertuzzo, R. Casagrandi, L. Righetto, I. Rodriguez-Iturbe, and A.

Rinal(2012), Generalized reproduction numbers and the prediction of patterns in waterborne
disease,Proc. Natl. Acad. Sci. Uniited States ofAmerica vol.23.,No 40.

Gorter C, Sandiford P, Pauw J, Morales P, Perez RM, Alberts H (1998). Hygiene behaviour
in rural Nicaragua in relation to diarrhoea. International Epidemiol. Vol.2,No 10.

Gracey M (1995). Diarrheal disease and malnutrition. Churchill Livingstone, Edinburgh

Gracey M (1996). Diarrhea and Malnutrition: A Challenge for Pediatricians. Botswana,vol.3

, No. 5.

Jamison, D. T., H. W. Mosley, A. R. Mea sham, and Bobadilla, J. L. (1993). Disease Control
Priorities in Developing Countries. New York: Oxford University Press.

Jensen P.K, Ensink J, Jayasinghe G, van der Hoek W, Cairncross S, Dalsgaard A.

Kosek M., Bern C., Guerrant R (2003). The Global Burden of Diarrheal Disease, As
Estimated from Studies Published Between 1992 and 2000. Bulletin of the World Health
Organization,vol.34,No 1
Marjatta BS (1994). Water supply and diarrhea in East African community. A case control
study on the quality of water supplies and the occurrence of diarrhea among small children
in a rural area of Western Kenya. University of Oulu Printing Center,
26

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Molbak K (2001). The epidemiology of diarrheal diseases in early childhood: A review

Molbak K, Jensen H, Ingholt L, Aaby P(1997). Risk factors for diarrheal disease incidence in
early childhood: a community cohort study from Guinea-Bissau. Am J Epidemiol. 1997;
146(3):273-82.
Of community studies in Guinea-Bissau. University of Copenhagen First Edition
Pascual, M., Bouma, M. J. and Dobson, A. P. (2002) Cholera and climate change).
pg 490 Rainfall, and fade-outs: a geostatical approach, In preparationHIV/AIDS. Lancet.
2002.

Rinaldo, E. Bertuzzo, L. Mari, L. Righetto, M. Blokesch, Rodriguez-Iturbe (2011),

Reassessment of the 20102011 Haiti cholera outbreak and rainfall-driven multiseason
projections. Proc. Natl. Acad
Ruiz-Moreno, D., Pascual, M., Dobson, A. and Bouma, M (2005), Cholera seasonality,

Sircar,B.K (1997). Risk behavioural practices of rural mothers as determinants of childhood

diarrhoea. Vol,4.,No 10
Snyder and Merson 1982 by Bern (1992) s well as to those reported in the first edition of
Disease Control Priorities in Developing Countries (Jamison et al. 1993).
Torres Codeo, C. T. (2001), Endemic and epidemic dynamics of cholera: the role of the
aquatic reservoir, BioMed Central Infectious Diseases 1:1.

Torres, C.T (2001). Endemic and epidemic dynamics of cholera: The role of the aquatic
Reservoir, BMC Infect. Curtis V, Cairn cross S, Yonli R. Review (2000): Domestic hygiene
and diarrhea pinpointing the problem. Tropical Medical International Health London,vol.50,
No 4.

27

V. Capasso and S.L. Paveri-Fontana (1979) A mathematical model for the 1973 cholera
Epidemic in the European Mediterranean region, Rev. Epidemiol. Sant Publique,vol. 27
(1979), 121132.

WHO (World Health Organization)(2000). Global Water Supply and Sanitation Assessment
2000 Report.
Woldemicael G (2001). Diarrheal morbidity among children in Eritrea: environmental

28

APPENDICES

Appendix I: Questionnaires
I am Japhet Kipngeno registered student at Mt. Kenya University pursuing a course leading
to the award of Master of Arts in Geography. I am required to carry out a Research Project
submitted to the Department of Humanities and Social Science in partial fulfillment for the
requirements of the award of the Master of Arts in Geography Degree of Mount Kenya
University.
All information given will be treated in confidence and will only be used for academic
purposes. I will appreciate any assistance accorded to me to collect the required information
for the research

29

Appendix II: Questionnaires

The following interview guide will be administered to school teachers, hospital staff and
parents to find out the spatial variation of diarrheal incidence in children at Kericho County

SECTION I: DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION

1 a) Your age category is:
25 and below ( ) 26-30 ( ) 31-35 ( ) 36-40 ( ) 41 and above ( )
b) Your gender is: Male ( ) Female ( )
c) Highest educational qualifications:
Certificate ( ) Diploma ( ) Higher diploma ( ) Bachelors ( ) Masters ( ) PhD ( )
Untrained ( )
d) Marital status:
Single ( )

Married ( )

Separated ( )

Divorced ( )

Widowed ( )

e) Occupation:
Peasant ( )

Employed ( )

Self-employed ( )

f) Your familys income per month:

( ) < 5000 KSHS

( ) 5000-10000 KSHS ( ) > 10000 KSHS

SECTION II: CLINICAL DATA

1. Hospitalized diarrheal cases per day..
2. Average weight per diarrheal case: kg. Average height: cm.
3. Average temperature for diarrheal case: .. 0 C.
4. State the number of days with diarrhea: .. days.
5. State stool frequency per day:
6. Do you find blood in stool when treating diarrheal cases? Yes /No
7. Do children with diarrheal vomit? Yes/ No
If yes, state vomiting frequency per day: -------------------------------------------------------------

30

8. Patients dehydration status:

( ) None

( ) Mild

( ) Moderate

( ) Severe

9. Did the child contact to any diarrheal patient for the last 7 days?

Yes/No

10. Did the child eat any food sold by street vendors for the last 7 days?

No/Yes

If

yes,

state

what

food

the

child

ate

..
11. Treatment before hospitalization: ..
..
12. Treatment during hospitalization:
..

SECTION III: KNOWLEDGE OF DIARRHEA

1. Do you know diarrhea? Yes/ No
2. If yes, what are the main signs/symptoms of diarrhea?
( ) Three or more unformed stools within a day. ( ) Vomiting ( ) Abdominal pain 2.6. Fever
( ) Cramps ( ) Blood in stool

( ) Nausea

( ) Other:

3. What do you think causes diarrhea in young children?

( ) Indigestible foods ( ) Teething
( ) Germ infection

( ) Worm infection

( ) other:

( )Dont know

4. What do you think spreads diarrhea?

- . -
- .. -
- . -
5. Do you think diarrhea is a hazard to the childs health?

Yes /No

6. Do you know some of the ways for preventing diarrhea? Yes/ No

If yes, mention some of them:
....

31

7. How did you know about diarrhea, signs, mode of spread and prevention?
( ) School

( ) Hospital

health worker ( ) Radio

( ) Television ( ) Friends

( ) Reading ( ) Village

( ) other:

SECTION IV. SANITATION AND RUBBISH DIPOSAL

1. Do you have a latrine?

Yes/ No

If no, how do you defecate yourself?

( ) Directly excrete into river/fishpond

( ) directly excrete on the ground

( ) other:

If yes, is it in use?
( ) Yes in use

( ) not in use

2. Is it private of public?
( ) Private

( ) Public

3. Type of the latrine used

( ) Modern toilet.
( ) Dry latrine ( ) Other : .

( ) Two-compartment latrine
4. How often is the latrine cleaned?
( ) Every time it is spoiled

( ) every day

( ) 1-2 times a week

Not

cleaned
5. How many people use the latrine? .
6. Do you think no cleaning of latrine can facilitate to spread diarrhea? Yes/ No
7. Are your children able to use the latrine on their own? Yes /No
If no, where do they defecate? .
8. If no in question 7, how do you dispose of the feces?
( ) Buried

( ) Put in the latrine

( ) Thrown away in open surrounding

( )Other :

9. What care is given to children after going to toilet?

( ) With water

( ) Other: .. ( ) Not clean at all

( ) With paper

10. Where do you dispose of household garbage?

( ) Rubbish pit

( )Other : ..

( ) Open surrounding

11. Where do you dispose of waste water?

( ) Sewage system

( ) Pond;

12. Do you use stool as fertilizer

( ) Garden

Yes/ No

32

( ) other: ..

SECTION V: HYGIENE PRACTICES AND OTHER DOMESTIC BEHAVIORS

1. Does your child feed on his/her own? Yes/ No
2. If yes, how does the child feed on his/her own?
( ) Other:.

( ) With spoon ( ) With his/her hands

3. Do you often wash the childs hands before eating? Yes /No
4. If yes, how do you treat the childs hands before eating any food?
( ) Washing by water only ( ) Washing by water with soap ( ) Others:

5. Do you often wash your hands?

5.1. After going to toilet?

( ) Never

( ) Sometimes ( ) Usually

5.2. After helping your child defecate?

( ) Never

( ) Sometimes ( ) Usually

5.3. Before eating and feeding your child?

( ) Never

( ) Sometimes ( ) Usually

5.4. Before preparing foods for your child? ( ) Never

( ) Sometimes ( ) Usually

6. How do you wash your hands?

( ) Water only;

( )Other:

( )Water and soap

7. Do you think that not washing your hands at 4 critical times in Question 5as well as No
hand-washing for the child before eating can spread diarrhea? Yes/No
8. Do you store cooked food for later use? Yes/ No
9. If yes, how do you store the cooked foods?
( ) In refrigerator

( ) in store

( ) in sufuria-cover

( ) Other:.

10. How long do you often keep the cooked food before reuse? .
11. Do you often heat the cooked foods before reuse? Yes /No
12. What do you use to clean utensils/containers for feeding your child?
( )Water only ( )Hot water only

( )Water with soap

( ) Hot water with soap

13. Do you often buy foods from street vendors for your child? Yes No
14. How often do you clean your kitchen?
15. Do flies present in the kitchen? Yes /No
16. Do animals enter the kitchen? Yes /No
17. Do you keep animals in the home overnight? Yes /No

SECTION VI: WATER RELATED PRACTICES

1. From what sources do you get your drinking water?
( ) Running water

( ) River

( ) Well ( ) Rain-water ( )Other

( ) Pond

2. What treatment is given to water before carrying home?

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( ) Filtering

( ) Chlorinating

( ) Using alum ( ) Other:. ( ) None

3. What kind of utensils do you use for storing water?

( ) Storage containers without lid

( ) Storage containers with lid

4. Do you always clean/empty the storage container before replacing with fresh water?
Yes/No
5. What type of water does your family use for drinking?
( ) Boiled

( ) Filtered

( ) Other: .

( ) Untreated

6. Where do you often bath your child?

( ) River

( ) Pond

( ) Bathroom ( ) Other

SECTION VII: BREASTFEEDING AND VACCINATION STATUSES

1. Do you breastfeed your child? Yes/ No
2. If yes, have you exclusively breastfed the child in the first six month of his/her life?
Yes/ No
3. If the child less than 6 months old, Have you exclusively been breastfeeding the child to
date ? Yes/ No
If no, how long by now have you introduced other foods to the child?
4. Do you know that breastfeeding adequately will reduce infections in a child? Yes/No
5. Has the child been vaccinated against measles? Yes No
6. What other vaccines has the child been vaccinated?
..

In brief this was a random probability sample of households designed to provide estimates of
health, nutrition, water and environmental sanitation, education and childrens rights
indicators at the national level, for urban and rural areas, and for the 11 provinces. The
sample was selected in four stages. A sample of 10, 305 households was drawn and 365
SEAs (Standard Enumeration Areas)were selected, with at least one cluster in each province
(Congo, 2002). The sample districts were selected following the Expanded Programmed on
Immunization (EPI) Cluster
Sampling Technique. Within each cluster, the required number of villages was selected
through the application of the EPI sampling technique. Within each village the required
number of households was selected randomly by spinning a bottle. Full technical details of

34

the sample are included in (UNICEF/DR Congo, 2002). The SEAs are the same as those
usedinthe1995 DRC
MICS1 (Zaire, 1996). The sample is a nationally representative sample of 11 provinces and
28 Districts In addition, out of 143municipalities (territories), 128 were included in the
sample.

35

Appendix III: Study Timeframe

Aug 2014

Sep 2014

ITEM TASK
1

RESEARCH
Proposal Topic
Literature
Review
Library visit
Proposal
completion
Questionnaire
completion
Proposal
submission and
defense

Data collection

Data Analysis

Report
compilation

Project
submission

36

Oct 2014

Nov 2014

May 2015

Appendix IV: Study Budget

ACTIVITIES

AMOUNT

Stationery

25,000

Typing

30,000.00

Binding for four final copies

5,000.00

Photocopy

20,000.00

Transport

100,000.00

Telephone/email

40,000.00

Miscellaneous

40,000.00

Total

KHS280,000.00

37