Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya

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Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya Carmen Anthonj ∗ , Andrea Rechenburg, Thomas Kistemann Institute for Hygiene and Public Health, GeoHealth Centre, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany

a r t i c l e

i n f o

Article history: Received 30 March 2016 Received in revised form 17 June 2016 Accepted 21 June 2016 Keywords: WASH assessment Behaviour Health risk perception Farmers Pastoralists East Africa

a b s t r a c t Wetlands can be both a blessing and a curse. They are beneficial sources of safe water and nutrition and places from which humans derive their livelihoods. At the same time, wetlands are known to be sources of disease-causing microorganisms and invertebrates that can threaten human health. Safe water, sanitation and personal hygiene (WASH) are crucial preconditions for the prevention of disease transmission. And of special importance for people living in wetlands, depending on and being exposed to them. WASH should be prioritized especially in those wetlands that are subject to intensive use, that have a poor sanitation infrastructure, and which at the same time only provide limited water resources. However, despite this critical importance, WASH in wetlands is not well characterized in literature. This study therefore aimed at providing insights into the water, sanitation and hygiene conditions and behavioural determinants of households in wetlands by presenting the case of a rural wetland in East Africa. The mixed method approach included a broad set of empirical data collected during a household survey (n = 400), an observational WASH assessment (n = 397) and in-depth interviews (n = 20) conducted from January to March 2015 in Ewaso Narok Swamp in Kenya. Different user groups of the wetland were targeted. The study in Ewaso Narok Swamp showed that wetland users’ water supply and storage, sanitation and personal hygiene conditions were inadequate for large parts of the community and significantly differed between groups. Whereas the WASH conditions of people working in the service sector were rather positive, for pastoralists, they were correspondingly negative. The WASH behaviour was also perceived to be inadequate influenced by a variety of determining factors. The observational index as applied in this study indicated to be a valuable, rapid and efficient tool for assessing domestic WASH and for detecting differences between different groups in wetlands. Combined with the quantitative and qualitative data, the approach served as a very helpful model to develop a multi-layered understanding of WASH conditions and related behaviour. The people in the researched wetland use by far less improved water sources and sanitation facilities than the nationwide average for rural populations. Since Ewaso Narok Swamp serves as a model case for the domestic WASH conditions in a rural wetland in semiarid East Africa, this fact make the study relevant not only at a national, but also at an international level. The results underline the previously formulated need of an integrative approach that first and foremost complements wetland management by public health interventions. In order to improve WASH conditions and to change behaviour in the long term, interventions should include the provision of clean water and sanitation infrastructure, as well as widespread health education. The approach proved to be useful for wetland environments and will be integrated into the development of a health impact assessment tool for wetlands. Moreover, it can be adopted in other contexts. © 2016 Elsevier GmbH. All rights reserved.

1. Introduction Wetlands are beneficial sources of water supply and nutrition, and places from which humans derive their livelihoods (Corvalán

∗ Corresponding author. E-mail address: [email protected] (C. Anthonj).

et al., 2005; Finlayson et al., 2015; Horwitz and Finlayson, 2011; Horwitz et al., 2012). According to the Ramsar Convention on Wetlands (1971) wetlands include swamps and marshes, lakes and rivers, wet grasslands and peatlands, oases, estuaries, deltas, reservoirs, rice paddies and other natural and man-made water resources. Wetlands provide vital ecosystem services by retaining large volumes of water, upon which humans strongly depend and expose

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Please cite this article in press as: Anthonj, C., et al., Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya. Int. J. Hyg. Environ. Health (2016), http://dx.doi.org/10.1016/j.ijheh.2016.06.006

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Fig. 1. Study area around Ewaso Narok Swamp, Laikipia, Kenya (Beuel et al., 2016; Leemhuis et al., in press).

themselves to. At the same time, wetlands provide aquatic environments with optimal conditions for the survival or profileration of certain bacteria, protozoa, viruses and helminths, as well as their hosts, reservoirs and vectors. Some of these organisms can cause diseases (Cools et al., 2013; Derne et al., 2015). Transmission occurs by the ingestion of contaminated water or through skin and mucous membrane surfaces by direct contact with water which is infested with parasites. The lack of adequate water for personal hygiene; and, to a certain extent, vectors in water environments, can contribute to disease transmission, too. Diseases that are mostly associated with wetlands include diarrhoea, cholera and typhoid fever (faecal-oral route), schistosomiasis (skin contact), malaria (vectors), and others (Appleton, 1983; Cools et al., 2013; Derne et al., 2015; Horwitz et al., 2012; Malan et al., 2009; Zimmermann, 2001). Safe water, adequate sanitation and personal hygiene (WASH) are crucial preconditions for the prevention of the named diseases. Inadequate WASH is responsible for almost 7% of the global burden of disease in terms of disability-adjusted life years (DALYs) and accounts for more than 4% of all deaths worldwide, most of which are of children in developing countries (Esrey et al., 1991; PrüssÜstün et al., 2014). WASH-related diseases and their consequences affect people’s quality of life, their agricultural productivity, their families and social networks, and consequently their overall socioeconomic development (Bartram and Cairncross, 2010; Hunter et al., 2010; Mara, 2003; Tumwine et al., 2002). As wetlands provide ideal habitats for disease-causing agents, WASH in such settings should be prioritized and addressed especially in such wetlands that are subject to intensive use by different groups, that have a poor sanitation infrastructure, and which only provide limited water resources. However, despite this critical importance, water, sanitation and personal hygiene in wetlands is not well characterized in literature. While the research needs have been clearly formulated, as for example by Derne et al. (2015), wetland-specific data on WASH has not been available. This research gap motivated the current assessment of domestic water supply, sanitation and personal hygiene conditions of people using wetlands. It draws on extensive empirical data collected from January to March 2015 to accomplish: (i) an assessment and quantification of the domestic WASH conditions of different wetland user groups through the application of an observational index; and (ii) an evaluation of perceptions of wetland users regarding WASH. The data gathered by different methods is triangulated and cross-checked against current health behaviour theories, such as

the theories on planned, motivated and habitual behaviour. Based on this, behavioural determinants for WASH are identified. Furthermore, it intends to contribute to the development of a health impact assessment tool for wetlands. Ewaso Narok Swamp (Fig. 1) presents one model case of a rural wetland and highland floodplain in semiarid Laikipia County in Central West Kenya. The Ewaso Narok Swamp is located about 250 km north of the country’s capital Nairobi by the town and administrative centre Rumuruti, which hosts about 33000 inhabitants, and near the town Gatundia of about 500 inhabitants. The 20 km long papyrus swamp has its main catchment in the Aberdare Mountains and receives seasonal floodwater from the Eng’are Narok and Mutara Rivers (Boy, 2011). The area is semiarid, characterised by low erratic rainfall (400–1000 mm annually), episodic rivers, and grassland. There are two distinct rainy seasons: a long one from March to May and a short one in November. Ewaso Narok Swamp is crucial for the livelihoods of its people, many of whom depend entirely on the wetland’s perennial surface water and natural resources. As in wetlands in other regions of East Africa, Ewaso Narok Swamp guarantees agricultural production food security, domestic water, livestock grazing, as well as offering other diverse uses (Sakané et al., 2011; Boy, 2011; Thenya, 2001). Accordingly, it is a magnet for an increasing number of people. The consequences of population growth and extensive use are apparent in the degradation of the ecosystem, inadequate waste management and deterioration of water quality and quantity (Boy, 2011). Located in a rural setting, the access to safe water and sanitation in the Ewaso Narok Swamp is generally low. Therefore, many inhabitants use surface water in the so-far under-researched wetland for drinking. The so far under-researched wetland is of critical importance to large parts of the population because it forms the most important source of water in the region. The study pursues the overall aim of contributing to filling the research gap on domestic WASH in wetlands by presenting a model case and data from the household level. The objectives of the research are relevant with regard to Kenya’s Vision 2030 (2007), the SDGs and WHO/UNICEF JMP Water Supply and Sanitation assessment on water, sanitation and hygiene (2015). 2. Materials and methods Mixed research methods were applied. The study followed approaches taken in previous studies by combining multiple quantitative data collection with qualitative local knowledge and perceptions (Aiello and Larson, 2002; Few et al., 2013; Halvorson et al., 2011).

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Table 1 Criteria for the observational assessment of water, sanitation and personal hygiene.

Water Sanitation Hygiene

Negative score (-1)

Neutral score (0)

Positive score (+1)

water storage container uncovered with visible signs of pollution no sanitation facility on the premises

water storage container not covered but no visible signs of pollution unimproveda sanitation on the premises fewb visible signs of dirt on clothes, hands or body

water storage container is covered

severalb visible signs of dirt on clothes, hands, and body

improveda sanitation facility on the premises neat appearance, no signs of dirt on clothes, hands or body

a Improved sanitation is defined as one that hygienically separates human excreta from human contact and includes flush toilet, pit latrine with slab, connection to septic system and others. Unimproved sanitation includes buckets, shared sanitation and others (WHO/UNICEF JMP, 2015). b Personal hygiene was assessed based on a general range defined according to the discretion of the researcher.

2.1. Data collection The three most prominent wetland user groups were identified at the study site as a basis for commensurate samples. They included smallholder farmers (n = 106), commercial farmers (n = 95) and pastoralists (n = 99). The smallholder farmers (sh) mostly used Ewaso Narok Swamp for subsistence crop production of beans and maize at the fringe of the swamp near their houses. The commercial farmers (co) grew horticultures such as tomatoes, cabbage and fruits for large-scale sale while living to a certain extent in temporary settlements in the wetland. The pastoralists (pa) used the wetland for herding cattle, goats and camels. People working in the service sector (se) as sellers, tradespeople, mechanics and motor-bike taxi drivers were included as a fourth group (n = 100). They lived in nearby Gatundia, a central area with better water supply and sanitation infrastructure. The random samples (n = 400) representing those four groups were drawn from resident lists provided by local chiefs. For the pastoralists that lived in rather remote areas within the swamp, snowball sampling was applied in addition to the lists. The observational unit of both the WASH assessment and the survey was individuals heading households. A standardised questionnaire-based survey conducted in the households addressed general occupational and household information, wetland utilisation, domestic water supply; hygiene and health knowledge, health risk perception and behaviour. The questionnaire was administered orally in English, Kiswahili or one of the most prominent languages among the respondents, namely Kikuyu, Masai, Samburu, and Turkana. The survey contained both closed and open-ended questions. During visits of 400 households, water storage, sanitation facilities, and the personal hygiene of the wetland users were assessed. Structured spot observations could be employed in the households according to a prepared checklist (Table 1) based upon previous work from Herbst, (2006), Herbst et al. (2008) and Webb et al. (2006). Out of the 400 survey respondents, key informants for openended in-depth interviews were systematically identified based on anchor questions from the survey questionnaire. The chosen households equally represented the four different groups (n = 5 for each group). The interviews were designed to provide perceptions and explanations of the WASH situation and WASH behaviour by the wetland users. Each interview took 30–120 min and was audio-recorded. All interviews were conducted after obtaining an informed consent both for the survey and for the in-depth interviews with each participant and after ethical clearance. 2.2. Data analysis Firstly, the different wetland user groups were described according to the independent variables from the survey questionnaire. Secondly, the observational data from the household assessment were described separately per different user groups

for water storage, sanitation and personal hygiene ranging from positive (+1), to neutral (0) and to negative (−1). Pearson’s chisquared test and phi coefficients were calculated with IBM SPSS® 22 Statistics. A total WASH score was calculated for those households where observational assessments could be conducted for the water, sanitation and personal hygiene conditions. There scores for domestic water storage, sanitation and hygiene were added together in order to describe the overall domestic WASH situation. It ranged from very positive and safe (+3) to very negative and unsafe (−3). Minima, maxima, interquartile range, medians and confidence intervals were calculated and notched boxplots were designed (Wessa, 2015). Kruskal-Wallis H tests were carried out to detect differences in the WASH conditions between the wetland user groups. The audio-recorded qualitative data from the semi-structured interviews were transcribed by use of the software easytranscript® . The data were then analysed using ATLAS.ti7® software. Categories were predefined in a minimal way in order to ensure methodological transparency and to prevent misinterpretation. The categorization was based on main themes in the qualitative results that were addressed by the interviewees (Lawrence et al., 2016; Akter and Ali, 2014), including water source and quantity, lifestyle, education, health risk perception and health protective measures regarding unsafe WASH. The classified qualitative data were visualized by creating chord diagrams with Microsoft Excel® and the software D3® and delimited.io® The diagrams represent the combined perceptions of WASH and links to themes of all user groups. The thickness of the connecting lines in chord diagrams represents the percentages of respondents having mentioned the single connections. To all the foregoing data, some representative quotes of different group members were integrated into the results and discussion section. Furthermore, the observational assessment of WASH conditions was associated with qualitative data for the in-depth interview households. 3. Results 3.1. Characterisation of different wetland user groups The different wetland user groups differed in terms of their household characteristics, water sources (Fig. 2), school education, health risk perception and health-protective behaviour (Table 2). The households of the pastoralists had the lowest socioeconomic status and were the largest (6.5 members), whereas the people working in the service sector had the smallest household sizes (4 members), yet the highest socioeconomic status. 93% of the people working in the service sector used improved sources according to JMP (2015), but only 8% of the pastoralists did. The commercial farmers’ households were located closest to the Ewaso Narok Swamp (1.5 km), whereas the people working in the service sector lived in farthest distance (14 km). In terms of average school education, the people in the service sector had the highest (10 years),

Please cite this article in press as: Anthonj, C., et al., Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya. Int. J. Hyg. Environ. Health (2016), http://dx.doi.org/10.1016/j.ijheh.2016.06.006

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Fig. 2. Main drinking water source by user groups in Ewaso Narok Swamp. *Wetland water refers to surface water from Ewaso Narok Swamp which is being fetched for drinking. **Piped water, public taps and rainwater are classified as improved sources of drinking water, while water from vendors and surface water from wetlands are unimproved sources (WHO/UNICEF JMP 2015).

Fig. 3. Observational assessment of domestic WASH conditions by user groups in Ewaso Narok Swamp.

Table 2 Characterisation of different user groups in Ewaso Narok Swamp. Characteristics

Smallholder farmers (n = 106)

Commercial farmers (n = 95)

Pastoralists (n = 99)

Service sector (n = 100)

Household head interviewed (male/female %) Number of household members (mean) Number of children in household (mean) Qualitative description of socio-economic statusa School education of respondents (years) Never attended school (%) Improved water source (%)b Distance of household to wetland (mean/km) Exposure to health risks in wetlands (perception) (%) Applying health-protective measures (%)c

29/71 5 2 medium 4 36.8 52 2.5 74.5 84.9

31/69 5 2 medium 7 14.7 24 1.5 54.7 89.5

49/51 6.5 3 low 2 63.3 8 4.5 56.6 61.0

80/20 4 1.3 high 10 6 93 14 55 94

a The socioeconomic status (SES) is defined as differential access to desired resources and is used to explain and predict behaviour (Oakes and Rossi, 2003). SES depends on a combination of proxy measure variables, including occupation, education, income, wealth, and place of residence. Here, the SES is being qualitatively described for each group relative to the other groups. b Improved sources of drinking water include water piped into dwellings, yard or plot, public taps, protected springs, hand pumps and rainwater (WHO/UNICEF JMP 2015). c The application of health-protective measures refers to self-reported measures, actions, and behaviours undertaken in order to prevent WASH-related diseases.

and the pastoralists the lowest (2 years). Exposure to health risks in Ewaso Narok Swamp was mostly perceived by smallholder farmers (74.5%), whereas only 55% of the people working in the service sector did. The pastoralists were the ones who reported to least apply health-protective measures against WASH-related diseases (61%), and the people working in the service sector almost entirely did (94%).

3.2. Assessment of the water, sanitation and personal hygiene conditions of different wetland user groups The observational household assessment (n = 397) of the water storage, sanitation and personal hygiene conditions of different user groups in the Ewaso Narok Swamp reveals general trends (Fig. 3):

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3.2.1. Assessment of water storage The water storage score was significantly associated with the group membership (p < 0.001), with a moderate strength (Ф = 0.493). Water storage conditions were scored rather negative in the households. Especially the pastoralists had their water stored in polluted and uncovered containers (median: negative; negative scores: 65.5%; neutral scores: 29.8%). The commercial farmers’ water storage conditions were largely scored as negative, too, but were slightly better (median: neutral; negative scores: 36.5%; neutral scores: 43.2%). The smallholder farmers’ water storage was scored as neutral or rather positive (median: neutral; neutral scores: 39.1%) with 39.1%having adequate water storage. However, 21.7% of them had their water storage containers uncovered. The respondents from the service sector showed the most positive results in terms of water storage (median: positive; positive scores: 58.9%). 3.2.2. Assessment of sanitation facilities The sanitation score was significantly associated with the group membership (p < 0.001), with a moderate strength (Ф = 0.506). All groups’ sanitation situation was scored as neutral or negative, having either no or unimproved sanitation facilities in their homes or homesteads. The pastoralists’ sanitation was mostly inadequate (median: negative), 74.2% of them no sanitation facilities on their premises. Sanitation was scored as negative or neutral among the commercial farmers (median: neutral; neutral scores: 51.7%; negative scores: 41.4%) and the smallholder farmers (median: neutral; neutral scores: 65.6%%; negative scores: 23.3%). People working in the service sector achieved the best scores (median: neutral; neutral scores: 50.7%; positive scores: 28.8%). 3.2.3. Assessment of personal hygiene The personal hygiene score was significantly associated with the group membership (p < 0.001); however this association was weak (Ф = 0.325). The hygiene condition was scored generally rather positive among the user groups. The pastoralists had the lowest scores (median: positive; positive scores: 52.5%; negative scores: 38.4%), followed by the smallholder farmers (median: positive; positive scores: 64.4%), exceeded by the commercial farmers (median: positive; positive scores: 71.3%) and the people working in the service sector (median: positive; positive scores: 92%). 3.2.4. Combination of water, sanitation and hygiene observations for different user groups The water storage, sanitation and hygiene scores were significantly associated: the water score was associated with the sanitation score with a moderate strength (Ф = 0.506). The association of the water score with the hygiene score was weak (Ф = 0.232), as well as the association of the sanitation score with the hygiene score (Ф = 0.330). All associations were highly significant (p < 0.001). The added WASH scores and resulting overall WASH situations of the different user groups’ households (n = 309) in Ewaso Narok Swamp varied greatly as illustrated in the notched boxplots (Fig. 4). The people working in the service sector had the best WASH situation of all groups, followed in descending order by the smallholder farmers, the commercial farmers and the pastoralists. Groups differed significantly in their WASH situations (Kruskal-Wallis H test, p < 0.001). 3.3. Perceptions of domestic water supply, sanitation and personal hygiene The in-depth interviews disclosed wetland users’ perceptions and explanations for domestic water supply, sanitation and personal hygiene in Ewaso Narok Swamp (Table 3, Figs. 5–7 ).

Fig. 4. WASH situation of different wetland user groups in Ewaso Narok Swamp. *The figure shows the added scores for domestic water storage, sanitation and hygiene and resulting WASH situation. **Positive situation if score = >1; neutral situation if score = 0; negative situation if score < = −1 ***The scores are statistically significant (p < 0.001). ****Notched box plots (Wessa 2015). The box shows the interquartile range of the data. The whiskers display the minimum and maximum values. The line shows the median of the data. The notch displays the 95% confidence interval around the median.

3.3.1. Perceptions of water supply and explanations for unsafe water As mentioned by most of the respondents, the wetland remains the most important water source for many people living around Ewaso Narok Swamp (90%), despite the wide-ranging perception of it being unsafe. Factors impairing the quality of water included the multiple uses of the same sources for drinking, hygiene, farming, livestock watering and for other uses (65%). Livestock interaction was underlined as a major contributor to water contamination (50%). The lack of sanitation facilities served as an explanation for negative water quality (15%), causing faecal material from open defecation to enter drinking water sources (15%). The rainy season was perceived as contributing to the unsafe water supply, as well as floods carrying dirt from higher grounds into the wetland (30%). The lack of water in the semiarid swamp area was seen as negatively affecting water supply and quality (25%). Lifestyle and tradition played a major role in the respondents’ explanations in terms of water safety, too. Several respondents (40%) described the pastoralists as mostly using unsafe sources due to their nomadic lifestyle of migrating from one place to another. Unsafe domestic water storage was mentioned to be due to traditional habitual behaviour (30%), the lack of education (25%), and included other reasons, too. Unsafe water sources and limited water hygiene were perceived to be associated with several diseases, such as typhoid fever (40%), diarrhoea (35%), cholera (20%), intestinal worms (15%), schistosomiasis and malaria (10% each). Half of the respondents suggested concrete health-protective measures with regard to water, but only 25% reported actually applying them (Fig. 5). 3.3.2. Perceptions of sanitation and explanations for inadequate situation A lack of sanitation facilities in households all over Ewaso Narok Swamp was reported (35%), and as a consequence, the need to practice open defecation (30%). Some of the in-depth interview respondents (25%) perceived this to be the case especially among pastoralists due to their nomadic lifestyle in remote areas (10%). The rainy season was assessed as negatively impacting the sanitation conditions, as well as floods (5%) and multiple use of water (5%). Not using sanitation facilities was explained as determined

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Table 3 Framework for themes in qualitative results. Perceptions and explanations of water supply, sanitation and hygiene in Ewaso Narok Swamp.

Now when there is no water. The people use the same water from Ewaso Narok Swamp (co2). The pastoralists they migrate to different areas where there is water, and then they drink the same water as their livestock (se5). They don´t know the meaning of clean water (co2). Those people need to be taught, they need to be shown the way to handle swamp water (sh2).

Most of the people here, like these marginalised nomadic groups they normally use the bushes (se2).

There is no separation between livestock and humans, it is not hygienic (sh4).

Many people have an issue with sanitation, they don´t know (co3). Like some don’t have toilets. They don’t care, they are ignorant (se1).

We have to educate the people, it’s about their health. There are those people who are ignorant, who deny hygiene (sh2).

The wetland water causes diseases. If someone drinks the dirty water, they can be sick. Animals are in the water, people dump their waste in the water, people use the water as latrine to relive themselves and that is the same water they use in the house. When it rains, dirt is washed to the river. It’s the same water we use (pa5).

Diarrhoea is also common, because they don’t have toilets and there are intestinal worms (se2).

Eye diseases are also caused by dirty water. Even when you are stepping over dirty water you can get diseases (co2). When people have only low quality of water available for washing their skin, they get skin diseases (se5).

In the wetland, there is water which causes disease. If one doesn´t boil the water it gives problems (co4). There is a lack of information on how to protect yourself from diseases (sh4).

There is need to have latrines in your compound there is need to clean your compound, there is need to improve your sanitation and hygiene (co4).

To prevent diseases, the majority of the people do hygiene measures (sh2).

Education

Water sources

One problem is that the water is contaminated. ‘The people use the same water from Ewaso Narok Swamp for bathing (se5).

Water quantity

Because most of the marginalized groups [reference to nomadic pastoralists] do not have toilets in their homestead. When it rains, a lot of faeces are washed into the wetland. They normally take water where they collect it (se2).

Those people in the rural wetland areas, they depend on rain and river water. There are those who have wells, but let me say, not protected wells. Most houses don`t have tap water (se3). The water is not clean and it´s the same water we are using for everything (pa4). We lack good sanitation, latrines and the bathrooms, so we have to go to the wetland for the services and we also let the animals drink from there. This just contaminates the whole water (pa4). When it rains, dirt that is on the ground gets washed to the river and it’s the same water we use (pa5).

Lifestyle

Hygiene

Health risk perception

Sanitation

Protective measures

Water

Due to a lack of enough water, personal hygiene could be low (se3).

*

These selected quotes reflect information gathered during open-ended in-depth interviews (n = 20). The individuals interviewed belonged to four different user groups, namely smallholder farmers (sh), commercial farmers (co), pastoralists (pa), and people working in the service sector (se). Each group is represented with n = 5. **

by tradition and habits (25%) and by a lack of education (20%). Inadequate sanitation was perceived to be linked to the risk of contracting diarrhoea, cholera and intestinal worms (5%). Still, only 10% of the people interviewed suggested concrete measures to improve sanitation (Fig. 6). 3.3.3. Perceptions of hygiene and explanations for poor personal hygiene The inadequate water sources (25%) available were reported as being responsible for poor personal hygiene. Water that was being used for various purposes and by different groups (35%) was seen as

impairing personal hygiene, with water scarcity and semi-aridity contributing as well (15%). Lifestyle and tradition were associated with poor personal hygiene. In this regard, the pastoralists were mentioned by almost one third of the interviewees (30%) due to their lifestyle as nomads in dry areas living in close proximity to livestock (40%).Poor personal hygiene was explained by habitual behaviour (20%) and was linked to a low education level (15%). Eye (65%) and skin (60%) diseases as well as diarrhoea (10%) were attributed to poor personal hygiene. Fifteen percent of the respondents suggested hygienic measures for health protection, and 10% stated they would not apply any such measures Fig. 7).

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4. Discussion This study assessed the domestic WASH conditions and examined behavioural determinants of different wetland user groups. 4.1. The differences of WASH conditions between different user groups As has been outlined, the water supply and storage, sanitation and personal hygiene conditions of the different user groups in Ewaso Narok Swamp vary greatly. Linking the observational WASH assessment (Figs. 3–4) to the characterizing variables of the different groups from the survey (Fig. 2, Table 2), to perceptions and explanations of WASH (Table 3, 4, Figs. 5–7), an approximation to the reasons for differences between the groups contains the following: Out of all investigated groups, the pastoralists turn out to have the worst WASH conditions. The water sources available are predominately unimproved and unsafely stored. Factors perceived to cause unsafe water conditions include the limited access to improved sources, and the least available water quantities compared to the other groups. Noticeable was that the vast majority of pastoral households surveyed had no sanitation on their premises. During the in-depth interviews, they were the group that was described and described themselves to have least access to sanitation facilities and to practice most open defecation, which corresponds to the quantitative results. They were also perceived having the poorest personal hygiene. All has been mostly attributed to their nomadic lifestyle in dry and remote areas and in close proximity to their livestock and to traditional habitual behaviour. Most are lacking school education, have a relatively low level of health risk perception and undertake the fewest health-protective measures of all groups. On top of this, their socioeconomic status is low compared to the other groups. The commercial farmers’ WASH situation is rated as neutral, which is associated with their limited access to improved water sources. Furthermore, the close proximity to the wetland might be a cause. Despite their relatively higher education levels compared to the other groups, their health risk perception is not high. Nonetheless, many health-protective measures are undertaken. The smallholder farmers perform rather positively despite their relatively limited school education. This is due to the fact that half of the group use improved water sources and live at a distance from the swamp. Furthermore, they have a high health risk perception and undertake many health-protective measures. The positive situation of people working in the service sector is likely accounted for by their high access to improved water sources, higher socioeconomic status, higher education levels, as well as increased health risk perception and implementation of healthprotective measures. 4.2. The implications of water sources and water quantity on WASH

Figs. 5, 6 & 7. Perceptions and explanations of unsafe water, inadequate sanitation and poor personal hygiene in Ewaso Narok Swamp based on in-depth interviews (n = 20). *The thickness of the connecting lines in the chord diagram represents the percentages of respondents having mentioned the connections between unsafe water, inadequate sanitation or poor personal hygiene and the linked aspect.

Safe water sources are inaccessible for a large share of the wetland population. As the household survey in Ewaso Narok Swamp reveals, only an average of 44% of the people use socalled ‘improved’ water sources (Fig. 2). Comparing this number to the average for rural Kenyan populations (57%) according to the JMP (2015), the access to safe water sources of households in the researched wetland is lagging far behind those country-wide numbers. Considering the high discrepancies between the different user groups paints an even gloomier picture, as the access to improved sources for pastoralists, for example, is elusively low with only 8% in the research area using such sources. The term ‘improved’ sources suggests protection and safety of water at the point of source that

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otherwise can be faecally contaminated and microbially unsafe at the point of consumption (Clasen and Bastable, 2003; Fewtrell et al., 2005; Hoque et al., 2006; Sobsey, 2002). In the researched wetland, as domestic water storage and handling revealed to be poor throughout about half of the households, the drinking water can likely be unsafe. Domestic water is considered one decisive determining factor for safe drinking water, adequate sanitation and good personal hygiene (Sobsey, 2002). Ewaso Narok Swamp, source of domestic water for numerous inhabitants, is perceived to be inadequate to provide safe WASH due to multiple water use and misuse, a lack of sanitation facilities, and seasonal phenomena such as flooding. Besides the water source, the water quantity is a key factor in terms of WASH, as has been outlined in the in-depth interviews. As in other semiarid areas, the access to water is associated with considerable distances in reaching any source, regardless of its quality (Prüss-Üstün et al., 2014; Sobsey, 2002). The users need to invest more efforts and time for collection and transport, which amplifies the risk of using and consuming unsafe water. The factors of effort and time both impair the quality of WASH (Hunter et al., 2010). Where safe water is scarce, it is being used according to the most pressing needs of humans, their livestock and livelihoods thereby becoming a driving factor for poor hygiene, which under such circumstances is less of a priority (Fewtrell et al., 2005). Where safe water is scarce, adequate sanitation is difficult and even impossible. In Ewaso Narok Swamp the more remote or marginalized a household or homestead is located, the less probable is its access to a sanitation facility and the more likely the household members practice open defecation. This practice is perceived to negatively influence water quality, as the contaminants are washed into the ground- and surface water (Sobsey, 2002), which the people depend upon, especially in the dry season.

(2003), ‘rural water supply, sanitation and hygiene do not only incorporate engineering, but also sociology’, and this is true in the case of Ewaso Narok Swamp (see also Herbst et al., 2009). In order to change this behaviour, hygiene education, awareness raising and socio-cultural acceptance are crucial tools, as for example applied in the Participatory Hygiene and Transformation (PHAST) system (Wood et al., 1998).

4.4. The implications of education on WASH Those possessing education and knowledge were described to be more likely to have positive WASH conditions, whereas the situation of those lacking education is worse. The information gathered during the in-depth interviews underlined, that low educational levels among wetland users were perceived as being a main cause for the use of unsafe water, for inadequate water storage and for performing inadequate sanitation in the Ewaso Narok Swamp. In this study, education was measured by the years spent at school or in education facilities. However, experience and knowledge can be acquired elsewhere, e.g. via the radio, newspapers or internet broadcast, health centres, from community health workers or family members. Such sources of information are not easily measurable and quantifiable but are important especially for the illiterate in particular when it comes to implementing WASH. According to Derne et al. (2015), education level and knowledge are crucial factors determining the WASH situation and behaviour and therefore for reducing exposure to disease risks in wetlands. Generally, however, one should consider that knowledge does not necessarily translate into practice (Curtis et al., 2009; Curtis et al., 2011).

4.3. The implications of lifestyle and traditions on WASH

4.5. The implications of health risk perception and health-protective measures on WASH

Lifestyle, traditions and habits turned out to affect WASH and related behaviour, especially in the case of the pastoral group. As could be observed during the household assessment, the nomadic pastoralists’ water supply, storage and sanitation conditions were mostly inadequate and compared to the other groups, their hygiene was lower. As the assessment revealed, only an average of 12% of the households had improved sanitation, whereas the other households had either unimproved or no sanitation at all (Fig. 3). Comparing this number to the average for rural Kenyan populations (30%) according to the JMP (2015), the access to improved sanitation of households in the researched wetland is lagging far behind those country-wide numbers. As observed with regard to water supply, again, considering the high differences between the groups shows the negative dimension clearer. Out of the pastoralist households assessed, none had improved sanitation, and 75% had no sanitation at all in their homestead and most probably practices open defecation. According to the perceptions of the wetland users investigated during in-depth interviews, in a culture of nomadism, the ownership of sanitation facilities is neither usual nor seen as extraordinarily useful, and often they are not used at all as construction is only done for a short period of time until the group leaves the temporary home (White et al., 2002). Living in close proximity to their livestock and with the environment is habitual (Curtis et al., 2011), and so is using surface water sources for drinking, river water for bathing and nature for open defecation. Accordingly, as water supply and sanitation are inadequate, personal hygiene deteriorates (Ezzati et al., 2005; Mara, 2003) and priorities are shaped according to the most pressing needs. Those needs likely dictate watering livestock over attending to personal hygiene. All of these aspects correspond with a negative overall WASH condition, but they are deeply rooted in culture and traditions. As stated by Mara

Health risk perception is closely linked to and can motivate the application of positive WASH-related behaviour as shown in a multi-country study by Curtis et al. (2009). In Ewaso Narok Swamp, the majority of the wetland users perceived a wide range of health risks stemming from the use of the wetland corresponding to the actual diseases prevalent in wetlands that pose risks to their users (Appleton, 1983). Whereas the survey revealed that more than 60% of the respondents generally associate wetlands with exposure to disease, the in-depth interviews gave more detailed information with regard to WASH. Unsafe water consumption was linked to several water-related diseases, such as diarrhoea, typhoid fever, schistosomiasis and malaria. Inadequate sanitation was named as causing diarrhoeal diseases. Eye, skin and diarrhoeal diseases were attributed to poor personal hygiene. These results show that people understand the situation and risks that come along with inadequate WASH in wetlands. However, when it comes to specific health-protective measures, the situation in Ewaso Narok Swamp presents a contradictory picture. Whereas more than 80% of the survey respondents claimed to apply health-protective measures in order to protect themselves against WASH-related diseases, very few participants from the in-depth interviews reported doing so and furthermore were barely able to suggest concrete measures. This indicates that despite their awareness of the health risks, they lack possibilities and/or detailed information on ‘healthy’ behaviour. There is a wide range of health-protective measures that vary among individuals and that require differentiation and separate detailed investigation. Different measures have different short-term and long-term implications on WASH, yet overall, it may be concluded that safe water, improved sanitation and good personal hygiene are health-protective measures per se (Curtis et al., 2011).

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Table 4 Association of WASH conditions with qualitative data in Ewaso Narok Swamp.

*These data reflect information gathered during a quantitative observational WASH assessment and qualitative open-ended interviews in the same households (n = 20). **The rows represent the households of smallholder (sh) and commercial farmers (co), pastoralists (pa), and people from the service sector (se), (n = 5 each). ***The columns represent the investigated aspects. The separate water, sanitation and hygiene (−1 = negative; 0 = neutral; 1 = positive) and the added WASH (−3 − −1 means negative, 0 means neutral, 1 − 3 means positive) scores are linked to, the qualitative perceptions on unsafe water, inadequate sanitation and poor personal hygiene.

4.6. Assessing domestic WASH by applying an observational index The aim of this study was to assess domestic WASH in wetlands and for this purpose, the observational index as developed and applied prove to be a helpful, rapid and efficient tool. It revealed that the wetland users’ water supply and storage, sanitation and hygiene are mostly inadequate. It showed that households with positive scores in either of the three categories (water, sanitation or hygiene) were more likely to score positively in the other categories. The WASH index facilitated the detection of differences between the different wetland user groups in Ewaso Narok Swamp. The advantages of such an index using spot checks had been shown before by Herbst (2006), who assessed household hygiene in Khorezm, Uzbekistan and by Webb et al. (2006), who did so in Bangladesh. However, in their study, they proposed that multiple measures are necessary to estimate the true hygiene pattern of a household as such an index can measure ‘proxies’ to behaviours rather than actual behaviours (Ruel and Arimond, 2002). The authors of this paper decided to follow this recommendation by applying multiple methods for identifying the behavioural determinants for the WASH of the different groups. The household survey and in-depth interviews disclosed that the inadequate WASH conditions were mainly due to limited access or the lack of facilities providing improved WASH. ‘Unhealthy’ behaviour was driven often driven by a lack of knowledge and information on the right behaviour to perform positive WASH. ‘Simple’ measures such as boiling water from unsafe sources or unsafe water storages before drinking were not consciously present to all. Reasons were manifold and included, besides the above discussed lifestyle, tradition and lack of education, economic amongst other reasons. This mixed method approach served as a valuable model to develop a multi-layered understanding of the domestic WASH situation

in Ewaso Narok Swamp. The results confirmed the importance to study WASH in wetlands and underlined the need of an integrative approach that complements wetland management by public health interventions.

4.7. Limitations This study has several limitations that should be mentioned. One limitation lies in the criteria for the observational assessment of personal hygiene. The assessment was based on a general range defined according to the discretion of the researcher. It addressed individual appearance, which does not serve as a good proxy for personal hygiene since it is likely to be caused by occupational characteristics. In order to address hygiene, the presence of handwashing options would have been a better indicator. Another major limitation of this current analysis is the lack of details on income and socioeconomic status of the wetland users. This study applied a newly developed analytical framework instrument that targeted the different user groups in order to provide a comprehensive overview on the situation in Ewaso Narok Swamp. As income and its implications on WASH is an equally viable approach that has been investigated before in other contexts, it was not taken into account for this current analysis. It would, however, have added more value to the study than a simple qualitative description. Through a focus on the domestic domain and observation of the inter-household WASH situation, a micro-scale contribution in assessing the situation in rural Kenya and in wetlands was effected. Intra-household variations were not distinguished, which might pose a limitation. Potential bias stemming from the design of the study that may have influenced the outcomes of the study was counteracted

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with systematic identification based on anchor questions from the survey questionnaire. Gender bias reflects the gender-specific occupational differences and was overcome by considering both the ex-ante and ex-post reflection of respondents from different genders and groups during the in-depth interviews and as reflected in Table 4. Seasonality might bias the findings as well, as it is obvious that there is a discrepancy in the WASH situation and behaviour in different seasons. This study was conducted in the end of the dry season, and the picture might be different in the rainy season. It must be pointed out that to fully capture WASH in wetlands, the public (Cairncross et al., 1996; Curtis and Yonli, 2000) and occupational (Anchang et al., 2014; Derne et al., 2015) domains of wetland users need to be taken into consideration. As work environments and any related exposure to contaminants and infectious agents and therefore health risks vary between different groups, more investigation is required to draw a complete picture. According to Curtis and Yonli (2000) and Prüss et al. (2002), the transmission of WASH-related diseases can take place via fluids, faeces, fingers, food and flies. Therefore, to entirely capture safe WASH and hygienic behaviour in wetlands, food and environmental hygiene should be integrated into the assessment. However, this study focuses on water, sanitation and hygiene and included only those observations according to the thematic choice.

health impact assessment tool for wetlands. Moreover, it can be adopted in other contexts. Acknowledgements This work was part of the project GlobE Wetlands in East Africa – Reconciling future food production with environmental protection, which is funded by the German Federal Ministry of Education and Research (grant number FKZ 031A250D). Ethical clearance was obtained from the Ethics Review Committee of Kenyatta University (reference number: KU/R/COMM/51/411) and the Ethics Committee of Bonn University (reference number: 246/14). We are especially grateful to the people of Ewaso Narok Swamp who enrolled in this study and allowed their data and experiences to be used for research purposes. We hope that the outcomes of this study will contribute to improving their situation. We would like to thank all Kenyan colleagues who collaborated in this research, including the GlobE Country Coordinator Helidah Oyieke (NMK, Nairobi) and our field assistants and translators. Last but not least, we thank our colleagues Christoph Hoeser and Dominic Schuld for the support with data visualisation. References

5. Conclusions To the best of our knowledge, this is the first investigation to assess and quantify the domestic WASH conditions of different wetland user groups and to identify the behavioural determinants in order to fully capture WASH in wetlands. The mixed method approach served as a valuable model to assess water, sanitation and personal hygiene and proved to be useful in developing a multi-layered understanding of the domestic WASH situation in households in Ewaso Narok Swamp. The observational index was a helpful, rapid and effective tool for detecting domestic WASH and differences between the different wetland user groups. A triangulation with the results of the household survey and the in-depth interviews proved to be successful and contributed to a better understanding of WASH in wetlands. The integration of social scientific methods helped in approaching the complexity of the topic and allowed a more in-depth examination and exploration of WASH and behavioural determinants. The case of Ewaso Narok Swamp showed that wetland users’ water supply and storage, sanitation and personal hygiene may be inadequate and significantly differ between groups. The results showed that the people understand the situation and risks that come along with inadequate WASH, but largely lack access to improved WASH. This makes structural improvements necessary to close the WASH gap. The facts that the people in the researched wetland use by far less improved water sources and sanitation facilities than the nationwide average for rural populations make this study relevant at a national and international level, as the Ewaso Narok Swamp serves as a model case for the domestic WASH conditions in a rural wetland in semiarid East Africa. The results confirmed the critical importance to study WASH in wetlands and underlined the previously formulated need of an integrative approach that first and foremost complements wetland management by public health interventions. In order to improve WASH conditions and to change behaviour in the long term, interventions should include the provision of clean water and sanitation infrastructure, as well as widespread health education. The approach proved to be useful and productive for wetland environments and will be integrated into the development of a

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