Participant recruitment and moderator training.

NRC led community mobilization and recruitment efforts. Before recruitment, NRC engaged community leaders and members regarding the purpose and scope of this project and explained the overall sampling strategy. A purposive sampling method, centered on gender and language, was used to ensure an adequate number of Somali and Dinka participants. Moderators, who lived in the camp and spoke English and at least one of the FGD languages (Dinka or Somali), led each FGD. In preparation, each moderator participated in a 2-day training session to review FGD techniques and discuss the moderator’s guide.

Data collection.

We conducted 12 pre-implementation FGDs, divided equally by language and gender (Fig 1). Each FGD had 6–10 participants, lasted approximately 90 minutes, and focused on the benefits and challenges of the current sanitation system and ideas for improvements; all FGDs were audio-recorded. Following the initial set of FGDs, participants also completed a pre-implementation survey, which was used to establish an understanding of household demographics and sanitation needs. Sanivation used the pre-implementation FGD data to better understand sanitation challenges in the camp and to inform the design of a complete sanitation system.

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Fig 1. Flow chart outlining qualitative and quantitative methods used.

https://doi.org/10.1371/journal.pone.0180864.g001

Intervention selection criteria.

Households that participated in the pre-implementation FGDs were asked about their interest in participating in a six-week pilot of a novel sanitation system. Of those interested, 32 households were randomly selected in three geographic clusters, after controlling for a representative sample of households with disabled and/or elderly persons. Two Somali households withdrew from the study in the first week and were replaced. Thus, in total, 16 Somali and 16 Dinka households were selected to pilot the new sanitation system (Fig 1).

Intervention description.

Sanivation used the data from the pre-implementation FGDs to inform the design of an alternative sanitation system (described below) to include: a regularly serviced toilet unit, solar waste treatment, and the production of charcoal briquettes. The new toilets were designed with two openings, one for urine and other liquids and one for feces, to promote cleaner and more efficient disposal of the waste material.

Each of the 32 participating households received a urine and liquid diverting, container-based toilet (Fig 2), a waste disposal bin for menstrual hygiene products and other nonorganic solid waste, and an ash container to store ashes from cooking to be placed over the feces as a desiccant. Based on the results of pre-intervention FGDs and survey, three container-based toilets with different characteristics, all designed to meet the needs of displaced populations, were selected for the pilot: 1) MoSan (Mosan, Zurich, Switzerland), a completely pre-fabricated and highly portable sit toilet; 2) Choopoa (Sanivation, Naivasha, Kenya), a locally resourced and fabricated sit toilet; and 3) SafiChoo (Wish for Wash, Atlanta, USA), a partially pre-fabricated sit/squat toilet (Fig 2). Household members received an orientation from study staff about how to use the toilet, including guidance on the use of ashes to aid in odor control and instructions to call service representatives if they had questions about the toilet. Trained service representatives visited each household twice per week to collect and replace waste containers. Service representatives transported the filled containers to a central location within the camp, where a locally fabricated solar concentrator, which captures solar energy to thermally inactivate pathogens in fecal waste, rendered the waste material safe for reuse.[22] Treated feces were combined with other waste products, including charcoal dust, to create briquettes for heating or cooking. (For a more extended consideration of the design of the solar concentrator and pathogen inactivation data see http://sanivation.com/). The briquettes were tested for safety and performance, but were not distributed to study households. However, participants were asked about their willingness to use treated waste for fuel. The pilot implementation of the service-based sanitation system was planned as a six-week intervention in Kakuma, after which, the pilot would be assessed to determine suitability for potential scale-up. From the outset, it was envisaged that modifications may be necessary as a result of the pilot, thus, the protocol included decommissioning of the toilets at the end of the pilot period. All study households were made aware of this as part of the informed consent process.

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Fig 2. Images of the three urine-diverting, container-based toilets included in the study.

(A) Choopoa, (B) SafiChoo, and (C) MoSan; (D) Choopoa.

https://doi.org/10.1371/journal.pone.0180864.g002

Data collection.

Throughout the implementation, bi-weekly surveys were conducted at weeks 1, 3, and 5 in each intervention household to facilitate routine monitoring, promote hygiene, and evaluate user satisfaction (Fig 1). If possible, we interviewed both the female and male heads of household; however, at least one member was interviewed. Additionally, fecal containers, collected twice weekly from toilets at each household, were weighed to help track toilet usage. If a household decided to voluntarily withdraw from the intervention, we discontinued bi-weekly surveys and invited an adult household member to participate in the post-implementation FGD.

Data collection.

Following implementation, one representative from each intervention household was assigned to one of four post-implementation FGDs, with 6–10 participants each, organized by gender and language (Fig 1). Topics of discussion included the impact of the intervention on the family’s life, noted challenges, perceptions of the collection process, perspectives on a possible scale-up, and opinions regarding the use of briquettes made from the treated waste.

Qualitative data.

Certified translators for each language transcribed the audio recordings; the transcripts were then translated into English. Study moderators reviewed the English transcripts to ensure consistency between the audio recording, the original transcript, and the English version.

The moderator’s guide and FGD transcripts were used to develop a codebook organized by theme. NVivo^® qualitative data management and analysis software was used to support coding and analysis (NVivo^® Version 10, Burlington, M.A.). Transcripts were coded independently by two members of the research team, and codes were compared for inter-rater reliability.[23] No personal identifiers were collected or included in subsequent reports.

Quantitative data.

Trained surveyors used a combination of hard-copy surveys and an Android mobile platform, Mobenzi^®, to gather the pre-implementation and bi-weekly survey data. Data were analyzed at the household level. The female head of household’s responses were chosen in instances where both the male and female were interviewed. Likert-scale and demographic data were collected. Given the limited sample size, only frequencies are presented.

Pre-implementation participant demographics.

A total of 107 camp residents participated in the 12 pre-implementation FGDs. Each FGD had between 6–10 participants and lasted approximately 120 minutes. Slightly more Somali speakers than Dinka speakers, at 57.0% and 43.0%, respectively, and slightly more women than men, at 57.9% and 42.1%, respectively, participated (Table 1). FGD participants had a median age of 27 years (range 18–60) and had lived a median of 7 years in Kakuma (range <1–22). Participants reported a household size of 2–36 persons, with a median of 8 persons. The median number of household members ≤18 years old was five. In total, 61.7% of pre-implementation FGD participants reported owning a latrine (Table 1). Reported latrine ownership among Somali and Dinka ethnic groups was 72.1% and 47.8%, respectively (Table 2).

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Table 1. Demographic characteristics of participants in the pre- and post-implementation FGDs, Kakuma Refugee Camp, Kenya.

https://doi.org/10.1371/journal.pone.0180864.t001

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Table 2. Gender and latrine ownership by nationality in the pre- and post-implementation FGDs, Kakuma Refugee Camp, Kenya.

https://doi.org/10.1371/journal.pone.0180864.t002

Previous sanitation experiences.

Participants described a range of sanitation experiences before their arrival at the camp. Dinka participants, often from rural villages, were more likely to report the previous use of open defecation. Both men and women described going into the forest or the “bush” for urination and defecation. At times, this practice was described as a product of culture or tradition, as indicated by a Dinka male, “…we did it as a cultural way of life.” However, it was most often described as a necessity and attributed to a lack of resources and education. One Dinka woman stated, “People were not educated [in] those days… [w]e could just go and defecate in the forest.”

Unlike Dinka participants who consistently noted similar sanitation patterns, Somali experiences were more varied. Many Somalis reported having consistent access to improved sanitation before arriving in Kakuma. While some detailed living a more nomadic lifestyle that included open defecation, most noted the use of concrete or wooden structures with drop-hole covers or latrines made of brick that channeled to a septic tank. One male participant described the latrines he used before coming to the camp as, “…the normal latrines that are found in mansions and big houses.” According to participants, these latrines could better accommodate individuals with special needs, including pregnant women, individuals with disabilities, and the elderly.

Reported benefits of current sanitation in Kakuma.

While both groups applauded the cleaning supplies provided by NRC, which aided in latrine cleaning and upkeep, overall perceptions of sanitation at the camp varied primarily according to group membership. For most Dinka participants, sanitation at the camp was generally viewed as a marked improvement. Using latrines was better than open defecation. One Dinka male stated, “[H]ere it looks totally good as compared to going to the bush.” Despite citing a need for additional latrines and more cleaning and construction supplies, Dinka perspectives generally associated latrine use, as compared to open defecation, as a step toward more modern sanitation practices. When referencing sanitation at the camp, a female Dinka participant noted, “Here at Kakuma, we tend to live like people who have gone to school and like rich people, or like very responsible people.” For Somali participants, many of whom reported having used improved sanitation before coming to Kakuma, the current sanitation system was not described as an improvement but rather as a system largely in need of improvements.

In general, Somali men and women recognized that sanitation options at the camp were limited. Latrines were described as affordable and as a better option than open defecation. However, latrines were used because they were provided. One Somali woman offered, “I only like this because I cannot see any other.” Similarly, reflecting the sentiments of a number of Somali participants, one male offered, “It is only better than defecating openly because in open defecation you see the feces.” This theme was present throughout the Somali FGDs, irrespective of gender.

Reported challenges of current sanitation situation in Kakuma.

When both Dinka and Somali participants noted the challenges of the current system or offered critiques, three broad themes emerged: lack of latrines/overcrowding, latrine cleanliness, and latrine design/construction.

Lack of latrines/Overcrowding. Both Somali and Dinka participants frequently reiterated the need for more latrines, “What we lack is latrines; the ones available are not enough for us” (Dinka male). Some Dinka families with inadequate latrine access sometimes engaged in open defecation near the river bank. “The number of latrines is fewer than the number of users; for example, one latrine might be shared by at least 20 people” (Dinka female). During one of the FDGs, a Dinka woman shared a very telling picture of the magnitude of overcrowding, “[I]n our area, one latrine is shared by 10 households, which consists of adults and children; these get filled up after about 1 month.” Her description was not isolated, but echoed sentiments expressed in all the Dinka pre-implementation FGDs.

Somali participants reported sharing a latrine with an average of 10 family members. However, like Dinka FGD participants, Somalis also discussed the need for more latrines. “We do not like the system, but we have been provided it. One latrine, irrespective of household size, is what is permitted to us. We wish to have two, or even four, latrines” (Somali woman). Overcrowding also influenced participants’ preference for sit versus squat toilets. Households that shared a latrine with fewer than 10 people preferred a sit toilet, while households that shared a latrine with more than 20 people preferred a squat toilet. This was due to hygiene reasons where less people were likely to keep the sit toilet clean than when shared by many.

Latrine Cleanliness. Although participants from all of the FGDs indicated that some cleaning supplies were provided, the need for more cleaning supplies was often cited. Dirty latrines, exacerbated by overfilling, were described as having a foul odor and serving as a breeding ground for insects, namely cockroaches. When describing some of the challenges with his latrine, one Somali male noted the, “unpleasant smell that gets into our house…and… our houses are infested by cockroaches from the latrine, especially from those filled-up ones.” Dinka women and men noted their frustration with practices that contributed to perpetually dirty latrines, such as lack of drop-hole covers, and use of communal, rather than family-owned, latrines, which made it difficult to assign responsibility for cleaning.

Latrine Design/Construction. Though rarely noted in the Dinka FGDs, Somali participants were very concerned about the design of the latrines, which they believed were not well-suited for special populations. According to Somali participants, children were at risk of falling in and the elderly and disabled had difficulty with the lack of a comfortable and safe place to sit. One participant noted, “There are different categories [of] users. They include the aged and disabled, who can’t use these latrines because they don’t have a raised sitting place.” (Somali male). Somali participants also indicated that the latrines were poorly suited for pregnant women and sick individuals.

Suggestions for improvements.

Participants had a number of clear recommendations for improvements to the sanitation system in the camp, including increasing the number of latrines to better accommodate the growing camp population, consistently providing cleaning supplies to reduce the presence of odor and control pests, and incorporating options more appropriate for special populations a raised seat for special populations.

Post-implementation participant demographics.

A total of 30 residents participated in the four post-implementation FGDs (Fig 1). Each FGD had between 6–10 participants and lasted approximately 90 minutes. There were slightly more Dinka participants than Somali, at 53% and 47%, respectively, and slightly more women than men participated, at 57% and 43%, respectively. FGD participants were an average of 30 years old (range 17–66) and had spent a median of 5 years in Kakuma (range <1–23). Participants reported an average of 10 persons per household (Table 1).

Reported benefits of the new system.

Participants noted several benefits associated with the use of the new system. The benefits described were strikingly similar across all groups and included: the reduction of any foul odor, reduction of insects/pests, the sitting design of the toilets, the appropriateness of the new toilets for special populations, and waste collection.

Reduced Smell and Reduced Pests. Attributed to both the waste collection and the use of ashes, participants noted that the new toilets did not smell, either at all or considerably less than the previous system. During one of the FGDs, a Dinka male shared, “We have realized that we were given very good [toilets]. I like using it because of lack of foul smell.” Participants also reported a reduction in the presence of roaches and other pests.

Sitting. The sitting feature was cited as a positive attribute in all of the post-implementation FGDs. Participants often spoke specifically about their own experience. Reflecting sentiments shared in all of the FGDs, one Dinka female indicated, “I like it because there is no more squatting. My knees ache no more because of squatting.” Similarly, a Somali male shared, “It gave us a relaxing position that makes one feel more comfort compared to the other latrines that we were using before.” The raised seat was also noted as extremely important and appropriate for elderly persons and people with disabilities. Instead of squatting or sitting on the slab, the new toilets allowed them to sit more comfortably. In general, the new toilets were also thought to be appropriate for most children, as they reduced the potential for falling in.

Waste collection. In all post-implementation FGDs, participant responses to waste collection were overwhelmingly positive. Men and women from both language groups described feeling thankful and cared for when the waste was removed. While discussing waste collection in the FGD, one Somali male stated, “I like the fact that we are being cared for and that, in a week, the container is replaced twice” (Somali male). Waste collection was viewed as healthy, limiting the accumulation of waste, a point of critique for the previous system. Participants preferred for their waste to be collected by someone else, and expressed discomfort at the possibility of carrying and discarding their own waste. Reflecting the sentiments of many FGD participants, one Somali male noted, “I feel good when [my] container… is replaced… I am also happy that someone else comes to collect it.”

Reported challenges of new sanitation system.

Participants were asked to discuss any challenges associated with use of the new system. Several challenges were noted, and ranged from perspectives on the toilet design to user experiences. Both common and group-specific challenges were considered. The most common challenges noted by both groups were toilet height and lack of roof.

Toilet Height. Although the toilet was considered appropriate for certain special populations, particularly elderly persons and those with a disability, there was some disagreement about the appropriateness of the toilets for very young children, particularly those younger than 3 years of age. According to the participants, the sitting basin was too high, at times posing a challenge for younger children.

No Roofs. The absence of a roof was noted as a challenge. Participants indicated that direct sun exposure made the toilet seats hot and, therefore, discouraged use. One participant shared, “I use it at night due to heat from the sun. If you sit on it at day time, one may end up with a burn” (Dinka male). Likewise, a Somali woman asserted, “When the sun is too hot, they can’t use it.” In addition to discouraging use, direct sun exposure caused an unpleasant odor and may have reduced the effectiveness of ash as a means of odor control.

Group-specific challenges.

Beyond those noted above, a few challenges were specific to each language group. These challenges often served as the basis for the user’s preference, especially for men, for the old or new system.

Somali Participants: Urine and Liquid Diversion. Somali users heavily critiqued the urine and liquid-diversion feature. This theme was pronounced in all of the Somali post-implementation FGDs. Both men and women had difficulty using the feature. Somali men and women practice anal washing as part of their belief system. According to the participants, having separate holes for the liquid contents and feces made this practice extremely challenging because it was difficult to direct the anal washing water into the urine and liquid hole without splashing into the other and, ultimately, discouraged frequent use. One Somali male indicated, “[B]ecause we are Muslims, [we] can’t keep moving from one hole to another. The previous latrine I used to visit 3–5 times in a day, unlike this one, that I can only visit 1–2 times in a day.” Additionally, several women had been subjected to female genital mutilation (FGM), which further limited their ability to use this feature. One Somali woman shared, “…especially for those who underwent female genital mutilation. It is hard for them to separate the two” (Somali female).

Dinka: Number of Users and User Demographics. Dinka households tended to have a greater number of users per toilet, with an average of 16 (range 7–40), presenting a challenge for some Dinka participants. As noted in the Dinka male FGD, Too many users made toilet cleaning and maintenance more challenging, especially when several of the household members were young children. Dinka males suggested that young children were more prone to misuse, thereby making the toilets dirtier and increasing the likelihood that the children would come into contact with human waste.

Dinka: Toilet Maintenance and Upkeep. Likely resulting from the high number of household and non-household users and a lack of cleaning supplies, Dinka participants indicated that toilet maintenance, specifically cleaning the toilet, was cumbersome and challenging. This influenced overall perceptions of the new system, particularly among Dinka males. “I do not see anything good with this new [toilet] because if it is not cleaned, it does not operate well” (Dinka male). While Dinka women also noted several challenges associated with toilet maintenance, these were most often associated with securing necessary supplies such as cleaning disinfectant and ashes—used to reduce smell.

Preference for new or previous system.

Both Dinka and Somali women reported a preference for the new system. Dinka women preferred having the waste collected, which reduced the presence of cockroaches. “I like the new type of [toilet]. I like it because when it gets filled up, it is emptied, unlike the old type that spreads cockroaches” (Dinka female). Similarly, Somali women preferred the waste collection of the new system. “We prefer them because after 3 days, the waste is being collected” (Somali female), noting a decrease in smell when compared to the previous latrines. When Somali women noted a preference for the old system, it was because they did not prefer urine and liquid diversion, at times due to FGM. However, in general, women described the new toilets as cleaner and more hygienic.

Unlike the women, the men’s opinions were more mixed. Dinka men preferred to sit on a toilet rather than squat over a latrine. Further, Dinka men indicated that the new toilets were easier to install (compared to digging a pit) and reduced foul odors and the presence of insects. When a preference for the new toilet was noted, it was qualified by the provision of cleaning supplies. One Dinka male noted, “It is good when emptied and washed, so that it smells good. It is comfortable to use then.”

Like Dinka men, Somali men were divided on their preference for the new system. Men who preferred the new toilets often referenced the sitting design. Similar to Somali women, the most salient critique of the new toilets was urine and liquid diversion, which made anal washing, an important religious practice, more difficult.

Thoughts on scaling-up the intervention.

When asked whether the intervention should be implemented in the newest area of the camp, Dinka men, Dinka women, and Somali women supported scaling-up the intervention, referencing the easy installation, the challenges of the old system, and the appropriateness of the new system for special populations. In contrast, Somali male perspectives were more varied. Those in support of the scale-up at times emphasized the need for redesign (removal of the urine and liquid diversion feature) and focused on the speed at which the new system could be installed compared to the previous latrines. Others were opposed to scale-up in new areas of the camp, but were in favor of scale-up in older areas of the camp, and noted several reasons, including: ample land in newer areas that could be used for pit latrines.

Thoughts on briquette use.

Most participants were open to briquette use. Some mentioned seeing this type of technology previously. Rare apprehensions regarding use centered on concerns about smell and safety, but did not appear to significantly deter interest.