African Population and Health Research Center

Report Part Title: INTRODUCTION

Report Title: Impact of Solid Waste Management on Health:
Report Subtitle: A Biomedical Study of Solid Waste Workers at Dandora Dumpsite,
Nairobi, Kenya
Report Author(s): Blessing Mberu, Abdhalah K. Ziraba, Dickson Amugsi, Ivy Chumo and
Kanyiva Muindi
African Population and Health Research Center (2019)

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CHAPTER ONE: INTRODUCTION

1.1 Background Information

Solid waste, which includes household refuse, non-hazardous solid waste from industrial and
commercial institutions, market waste, yard waste and street sweepings have been identified
among others as an indication of societal lifestyles and production technology (Schubeler et
al., 1996). However, improper solid waste management is linked to a wide range of risks
including the stagnation of economic development, the incidence of diseases, environmental
degradation and impact on livelihoods. This is especially true in urban settlements where huge
amounts of waste are generated within a very small area. The impacts of poor solid waste
management within cities and big municipalities on public health and the environment and
ultimately quality of life of all citizens have been highlighted (National Environment
Management Authority, 2014).

The estimated quantity of Municipal Solid Waste (MSW) generated worldwide annually is 1.7
– 1.9 billion metric tons (UNEP, 2010). In many cases, municipal wastes are not well managed
in developing countries, as cities and municipalities cannot cope with the accelerated pace of
waste production. Waste collection rates are often lower than 70 per cent in low-income
countries, and more than 50 per cent of the collected waste is often disposed of through
uncontrolled landfilling and about 15 per cent is processed through unsafe and informal
recycling (Chalmin & Gaillochet, 2009). In cities throughout Africa, as in other developing
regions, rapid population growth as well an expansion of service and manufacturing sectors
have led to an increase in the amount of solid waste produced, while its management has
remained highly deficient (UN-HABITAT, 2013). This is especially the case in poor areas
where limited or no waste collection takes place and where waste is collected, it is improperly
disposed of, typically in open dump sites or landfills, which are frequently situated in close
proximity to the city, particularly informal settlements.

The lack of formal systems to sort waste at source, and to control leakages and gas from dump
sites, exposes surrounding communities to a spectrum of health risks and threatens the
environment. By the same token, materials that are recovered for recycling – mainly by
informal and small-scale operations, are likely contaminated, thus impacting their safety for
re-use (CalRecovery Inc. & UNEP International Environmental Technology Centre (IETC),
2005; Hoornweg & Bhada-Tata, 2012). Existing evidence points to disproportionate
expenditure on collection versus disposal, poor municipal administrative abilities and a lack of
public funding, staff and equipment as key institutional constraints to appropriate solid waste
management (SWM) (UN-Habitat, 2010). The SWM phenomenon in Kenya is not different.
Municipalities all over Kenya are faced with a huge challenge in managing the increasing
production of municipal wastes, and recycling which is one of the key methods of reducing
MSW is not effectively used by municipalities and individuals who are into SWM. The
Dandora dump site, which is an official dump site of the city of Nairobi is overflowing with
waste. This is compounded by the activities of scavengers who dig through the waste for
valuable items. The consequential effect of the poor management of the Dandora dump site on
the environment and health of the surrounding communities and the people working at the site
cannot be underestimated but is yet to be quantified and documented. Consequently, the
African Population and Health Research Centre (APHRC) launched this study to empirically
examine the impact of exposure to the Dandora dumpsite on specific human health outcomes
among the most vulnerable waste workers in the City.

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1.2 Problem Statement
The problem of solid waste generation and the inability to manage it is of a great concern to
many countries in SSA. This is particularly the case because of the risks poor solid waste
management (SWM) practices pose to population health. Besides, poor SWM leads to the
occurrence of man-made hazards (Hambati & Gaston, 2015; Lamond et al., 2012), which have
a direct implication for the health of the population (Kimani, G.N. & UNEP, 2007).
Consequently, increased attention is being paid to the growing urban environmental risks that
threaten the well-being and prospects especially of poor city dwellers. Kenya typifies these
challenges, key among them being the often mutually exacerbating health hazards of SWM.
Nairobi, the largest city in the country, has only one official dump site at Dandora, which is
poorly designed and managed. This situation creates a conducive environment for disease
transmission agents. Available evidence shows that poorly managed and designed landfills
attract all kinds of insects and rodents that transmit disease to humans (Elliott et al., 1996),
especially to people who are directly exposed to the waste.

Recycling of solid waste carries with it health risks if proper precautions are not in place.
People working with solid waste containing chemicals and metallic elements may experience
toxic exposure (Lavoie & Guertin, 2001). Disposal of medical wastes requires more attention
as it can cause major health hazards, such as Hepatitis B and C, through wounds from discarded
syringes (Anagaw et al., 2012). Waste pickers and others who are involved in scavenging in
the waste dumps for items that can be recycled, may sustain injuries and come into direct
contact with these infectious items. This is the case for the Dandora dump site where not only
municipal waste is disposed, but also medical waste from health facilities, thereby exposing
the people working on the dump site to the risks of infections. It is important to note that the
Kenyan Ministry of Health in collaboration with its partners (MOH, 2016) have come out with
a five year (2016-2021) health care waste management (HCWM) plan to address the issue of
HCW in the country. This plan has elaborate HCWM strategies, which include but not limited
to clear delineation of responsibilities, occupational health and safety programmes, waste
minimization and segregation, protocols on HCW disposal, and documentation of best
practices/innovations. It is envisaged that the implementation of this plan over the next five
years will result in improvement and sustainability of HCWM in health care facilities, prevent
and reduce risks and mitigate hazards associated with poor HCWM in humans and the
environment.

Overall, occupational hazards associated with waste handling include infections (skin and
blood, eye and respiratory, and those transmitted by flies); chronic diseases (respiratory
diseases, cancers); accidents and injuries (bone and muscle disorders, poisonous and chemical
burns, burns and other injuries); and psychological disorders (stress, depression) (United
Nations Environmental Programme., 1996).

Although, the problem of solid waste management has been clearly described in the African
context, its impact on health of the different exposed population groups has not been explored
in a systematic manner. Indeed, making evidence on health impacts of solid waste management
available could inform the planning and delivery of health care services to the exposed and
affected population groups as well as the design of protective measures. In addition, knowledge
of health impacts of poor SWM could inform the formulation of polices that protect the health
and well-being of the most at risk populations. The present study seeks to establish the health
risks associated with SWM at the Dandora dump site, so as to provide policy makers with local

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evidence to design interventions to address the health needs of people who are directly exposed
to solid wastes.

1.3 Overview of Impact of SWM on Health Implications

Poor solid waste management can have impacts on human health in many different ways. The
population segments that are at high risk from poor solid waste management usually include –
those living in areas where there is no proper solid waste disposal method, especially children;
waste workers (collectors, transporters, and pickers); and people working in facilities that
produce toxic and infectious waste. Other groups at high risk include people living near dump
sites. Population groups whose water source has become polluted by leakages from solid waste
dumping or landfill sites are also at special risk. Uncollected solid waste and solid wastes
dumped at public sites could also increase the risk of injury, and infection. More importantly,
organic solid waste poses a serious risk, as they ferment, creating conditions suitable to the
growth and proliferation of microbial pathogens. Moreover, handling of solid waste without
proper protection can result in various types of infectious and chronic diseases with the waste
workers and the pickers being the most vulnerable (Pervez Alam & Ahmade, 2013).

In addition, exposure to hazardous solid waste, wastes that directly impact human health and
well-being, also poses greater risk. Children are more vulnerable than any other population
groups to hazardous solid wastes. Direct exposure to hazardous wastes could directly lead to
diseases through chemical exposure. This is due to the fact that the release of chemical waste
into the environment leads to chemical poisoning. Many studies have been carried out in
various parts of the world to establish a connection between health and hazardous waste with
some showing some grave impacts (Carter et al. 1996; De Rosa et al. 1996; Rushton, 2003).

Furthermore, solid waste from industries and agricultural establishments can also pose serious
health threats. Disposal of industrial hazardous waste together with municipal waste could
expose people to chemical and radioactive hazards (Giusti, 2009). Uncollected solid waste can
also block storm water drainage systems, resulting in flooding and the formation of stagnant
water bodies that serve as the breeding sites for disease causing organisms. Waste dumped near
or into a water source could also cause pollution of the source of drinking water (Zurbrügg,
2002). Dumping of solid waste into rivers, seas, and lakes would result in the buildup of toxic
substances in the food chain through organisms that feed on it.

Equally important is that disposal of medical waste from health facilities, also requires
exceptional attention since this type of waste can create major health hazards. This waste is
generated from the health facilities -hospitals, health care centers, medical laboratories, and
research centers – and includes discarded syringe needles, bandages, swabs, plasters, and other
types of infectious waste are often disposed with the regular non-infectious waste (Chaves et
al., 2013; Puri et al., 2008). This type of waste places people who are in contact with it at an
elevated risk to hepatitis B, C and other related infections. The preceding literature highlights
the health risks associated with solid waste and informs this study using objective measures of
health risks and outcomes related to exposure to SWM in Nairobi.

1.4 Research Objectives

The general objective of the study was to investigate the different health risks arising from
exposure to poor SWM practices and people’s knowledge and perception about these risks.

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The specific objectives of the study were to:

1. Assess the prevalence of infections (e.g hepatitis B, skin infections, intestinal infestations)
associated with exposure to wastes among waste workers at the Dandora dump site
2. Identify and estimate the prevalences of injuries and accidents associated with exposure to
wastes among waste workers at the dump site
3. Explore knowledge and perceptions of stakeholders and general public on the health risks
associated with poor solid waste management

1.5 Conceptual Framework and Operationalization

The empirical literature reviewed informs a multi-level conceptual framework to guide this
study. The resulting framework illustrates the various mechanisms through which exposure to
solid waste can lead to different health outcomes, both through direct pathways and through
mediating/intermediate outcomes. The framework, presented below, recognizes three
dimensions/sources of exposure to solid waste, which in the context of poor SWM, may include
organic waste, inorganic waste, objects and sharps, which could lead to adverse health
outcomes including infections, chronic diseases, poisoning, allergy and physical injuries. The
accumulation of solid waste can cause blockages that increase the likelihood of flooding and
also provides breeding sites for disease vectors. Organic waste could undergo decomposition
and create favourable conditions for vectors, micro-organisms and parasites. Exposure to
inorganic waste can cause acute poisoning, allergies and respiratory complications. On the
other hand, direct exposure to sharp objects could result in physical injuries and infections. For
example, exposure to sharp objects from medical waste can result in blood transmitted
infections such as hepatitis B and tetanus. Even though, waste dump sites are a nuisance to
many, they are also economic hubs to those with economic interest, including garbage
collection cartels and pickers. As a result of competing interests, dumpsites are often associated
with violent crimes, resulting in bodily injuries to those involved. Pollution of air from burning
inorganic waste and decomposing organic waste also exposes residents to the risk of chronic
respiratory diseases.

Figure 1: Conceptual Framework showing the pathways between exposure to solid waste
and adverse health outcomes

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Source: Ziraba et al., 2016

1.6 Research questions

The following specific questions guided the study:

1. What infections are associated with exposure to solid wastes?

2. What are the prevalence of injuries and accidents associated with exposure to solid waste?
3. What knowledge do stakeholders and the general public have about the health risks associated
with poor SWM at individual, household and community levels?

1.7 Study Design and Sampling Strategy

1.7.1 Study design

The study was a cross-sectional study conducted for a period of twelve months. The study
employed mixed methods approach (quantitative and qualitative) for data collection. The
qualitative component was aimed at deepening insights on the findings from the quantitative
survey.

1.7.2 Study site

The proposed study was conducted at the Dandora dump site; the only official dump site in
Nairobi. The dump site is located on the outskirts of Nairobi city, about 12 kilometers from the
city center. The dump site is an open sprawling area where the city county of Nairobi and
private garbage collectors dispose of solid waste brought in by trucks. The site shares a
boundary with the informal settlements of Korogocho and Dandora. The dump site is
frequented by waste pickers who retrieve re-usable articles from the waste.

1.7.3 Population
The study population included solid waste pickers who work at the dump site and garbage
collectors who bring in waste using trucks. On average, every truck has two operators who help

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with the loading and offloading of solid waste. They also at times double as pickers sifting
through garbage on their trucks for any valuable articles.

Inclusion criteria

Study participants were males and females, aged 6 years and above who were found working
at the dump site as either collectors or pickers during the time of study. Stakeholders and
members of communities bordering the dump site also formed part of the study population.

Exclusion criteria:

Individuals who, either due to physical or mental illness are unable to respond to the interview
or provide a specimen sample were excluded.

1.7.4 Measurements
The following measures were used to assess the primary outcomes:

i) Blood infections, where the test for hepatitis B was a marker infection;

ii) Urinary infections, where we did test for urinary tract infections;

iii) Haemoglobin level, where the level of haemoglobin of study participants was measured.
The Hb measurement was done at the field level using a portable Hb meter by a finger prick;

IV) Intestinal infestations: We did test for Ascaris lumbricoides; tapeworms (Taenia spp.),
Schistosoma mansoni or S. haematobium ova and hookworm (Ancylostoma
duodenale and Necator americanus). Presence of any of these constituted a positive result for
intestinal infestation;

v) Body lesions: physical examination was carried out by clinical officers to identify any
clinically significant infections/lesions;

vi) Injuries and accidents: Physical examination and/or self-reported cases were recorded;

vii) Reported morbidity in the past two weeks: Other outcomes of interest included reported
episodes of diarrhea, skin diseases and respiratory complications.

1.7.5 Sampling strategy for the quantitative survey

Sample size estimation was based on the design and occurrence of outcome of interest and
level of sample stratification desired. We had three strata by age: less than 18 years; 18 to 24
years and 25 years and above. The age stratification hinges on the fact that the spectrum of
individuals involved in solid waste management in terms of age is wide. We decided to use the
three broad categories each of which has adequate numbers to enable us compute indicators for
characterizing the population. The under 18 represent minors who are engaged in this
hazardous labor activity. The 18-24 represent young adults starting out life in employment
while the 25 and above represent older individuals. We were not seeking for equal age groups
partly because we do not have a ready sampling frame but also it would possibly add little
value. Having no strata at all would possibly misrepresent the study population structure, while
having too many would require a large sample size to be able to compute indicators for each
group. We very much thought that having the three categories might give us a variety of
exposure risks, which are partly correlated with length of exposure (and one's age) and
associated health outcomes.
6

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 We used the following sample size estimation formula to estimate sample size using the
outcome that gives a higher sample size:

𝑁 = (𝑍 % ∝/% ∗ P ∗ Q)/d2 (Kadam & Bhalerao 2010)

Where N is the required minimum sample size; Z is the normal distribution value
corresponding to two tailed test (1.96); P is the proportion of outcome of interest (intestinal
infestation-20% ref); Q =1-P and; d is the desired level of precision (5%).

The ideal sample size was 246, and therefore for the three age strata, the overall sample size
was intended to be 246*3=738. At the time of study, tension related to post election were still
high and therefore data collection and specimen collection was completed by 381 waste
workers which is 51.6% of the intended sample size. Due to challenges with finding minors
respondents as they are nowadays encouraged to go school, the respondents constituted 6.6%.
18-24 young adults starting out life in employment had not settled back to work as a result of
post-election tension and they constituted 22.6%. Therefore, majority of waste workers who
were in the dumpsite and work mostly during the day were aged 25 and above and constituted
70.8% of the respondents.

Given that there was no sampling frame for this population, we recruited participants using
systematic sampling. For those working with the waste delivery vehicles, we selected
participants at intervals of two trucks spread throughout the day and week. For waste pickers
(scavengers and collectors), we randomly selected the first participant and subsequently
selected at intervals of two individuals along a chosen path through the day and week until the
required sample size was reached. Details of each participant such as age, sex, place of
residence, and for those working on trucks, the truck registration number, was collected and
searched in the database each time a new participant is being recruited to ensure that no single
person was interviewed more than once.

1.7.6 Sampling strategy for the qualitative investigation

We used a purposive sampling technique to select study participants for the qualitative arm of
the study. This helped us focus on people we thought were better able to assist us understand
the health risks associated with SWM. The strata for qualitative interviews is summarized
below.

Type of Interview Cadre of Respondent Number

Key Informant Interviews (KII) Women Leaders in the dumpsite 4
Youth Leaders in the dumpsite 4
Recyclers/ Entrepreneurs of solid waste 4
Religious based organization/CBOs 2
Community Members around the dumpsite 4
In-depth Interviews (IDI) Scavengers/ Waste collectors 6
Waste pickers 6
Waste transporters 4
Total 34

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1.8 Data Collection

1.8.1 Quantitative data collection

The quantitative survey data collected was aimed at generating robust representative data on
the scope of socio-demographic patterns and correlates (age, sex, education, occupation,
ethnicity, religion, place of residence, and marital status) of the various health risks associated
with SWM as captured in study’s conceptual framework shown above. The survey data was
collected using a structured questionnaire, (annex 2), administered to selected waste workers
at the Dandora dump site. The quantitative survey tool was programmed into tablets.

1.8.2 Collection of specimen

Blood samples
The collection of the blood samples and physical examination was conducted by trained health
professionals. We hired a space in the outskirts of the dumping site, with audio and visual
privacy to allow for a general examination and drawing of specimen. We used auto-disable
syringes to draw 3-5mls of venous blood. Using aseptic technique, blood was drawn from the
arm of the study participants by venipuncture using an evacuated tube collection system and
kept in an EDTA vacutainer. Blood in the EDTA tubes was kept in a cool box with frozen ice
packs and transferred to the laboratory daily. This made it possible for the specimen to be
processed on the same day. The procedure of drawing the blood was guided by the WHO
guidelines on drawing human blood (best practices in phlebotomy) (WHO 2010).

Collection of stool and urine samples

To facilitate taking of stool samples, a mobile waterborne toilet was hired and kept at the site
for the period of the study. Participants who were not able to provide a specimen sample were
encouraged to either wait on site or return whenever they were ready and were given an
appointment card to ensure matching of the specimen and survey data. Participants were asked
to pass the stool sample directly into a plastic poly-pot cup with a tightly fitting lid. About 20
– 40 grams of well-formed stool or 5 - 6 tablespoonful of watery stool sufficed for the routine
examination. Stool samples were also kept in a cool box with frozen ice packs awaiting transfer
to the laboratory for analysis on the same day. A midstream sample of urine was also collected.
The urine sample collection was done by the study participants themselves based on the
following instructions: They were required to first cleanse the urethral area with a castile soap
towelette, which were provided by the study team. Additionally, study participants were
advised to void the first portion of the urine stream into the toilet. These first steps were aimed
at reducing the opportunities for contaminants to enter into the urine stream. The urine
midstream was then collected into a clean container (any excess urine should be voided into
the toilet). After obtaining the urine specimen the lid was screwed on tightly again being careful
to avoid touching inside the container or lid. We used standard microscopy to identify either
ova or parasites. This is because, standard microscopy is the gold standard for diagnosis of
intestinal parasite and helminthes as it focuses on identification of either ova, cyst trophozoites
or segments of the worm. The method for stool processing is the one that make the difference.
In this respect the processing method is the most important, thus stool was processed using
Kato Katz method.

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1.8.2 Qualitative data collection
The qualitative component complemented the quantitative data and involved key informant
interviews (KII) with local leaders, and individuals living in the neighborhood of the dump site.
This provided an indepth understanding of the underlying disparities in perceived health risks
associated with SWM and interventions put in place to reduce these risks. Study participants’
diversity was critical to our goal of generating robust and grounded knowledge on health risks
associated with SWM in informal settlements including community leaders, private sector
actors (community based organizations, private waste management companies and youth
groups who are into waste collection) and waste workers and pickers. The interviews were
conducted at the most convenient locations for the participants.

1.8.3 Training of field staff and piloting

The project recruited research assistants and professional transcribers for the quantitative and
qualitative data collection processes, who were taken through an intensive fieldwork training
using African Population and Health Research Center’s(APHRC) training protocol. The
training was facilitated by researchers from APHRC, including the principal investigator,
project manager, research officer, programmer, field coordinator and qualitative experts. The
objective of the training was to provide the field staff with a thorough knowledge of their role
in the data collection process. It entailed a combination of theoretical training (on the study
protocol) and practical exercises. Specifically, the training involved: Facilitated sessions on the
overall aims of the study, the study tools, research ethics; mock interviews; a field-based pilot
and a debrief session was conducted after the pilot to learn from their experience with the pilot.
In addition, training on the study protocol was provided for phlebotomists’ nurses, and medical
officers who collected the samples and conducted physical examination of study participants
respectively. This enabled them get a clear picture as to what the study is intended to achieve.

1.8.4 Ensuring data quality during fieldwork

The field staff were closely monitored by field supervisors to ensure that the data being
collected were of high quality. We had a dedicated office editor responsible for reviewing the
data on daily basis and providing the supervisors with frequent feedbacks on identified data
related issues. Data quality checks such as skips, and ranges was built into the program /
software. The office editor reviewed 100% of the completed interviews, to: a) check for
completeness of the data; b) ensure that all questions have been answered; c) checking for data
inconsistency. We implemented a continuous process of data quality checks in the field using
spot checks, sit-in interviews, and editing of completed surveys. For the spot checks, team
leaders randomly select 10% of the people interviewed for revisits. The health professionals
engaged were closely supervised by the project manager to ensure that they strictly adhere to
the study protocol.

1.8.5 Ethical considerations

All study participants were informed about the study before any consent to participate was
sought. Participants were adequately informed about the: purpose of the study and methods to
be used; institutional affiliation of the researchers; the right to abstain from participating in the
study, or to withdraw from it at any time, without reprisal; and measures to ensure
confidentiality of information provided. All participants provided a written informed consent
and were informed that participation is voluntary and no victimization of any sort was meted
if they refused to participate. For those who could not read, the consent form was read to them
by person they themselves identify. Also, before any medical procedures were carried out,
informed consent was obtained. For minors, we obtained consent from their guardians and
assent from the minor before they participated. Participants were given 500 Kenya shillings

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(approximately USD 5) for lunch and lost earning opportunity. No other material benefits were
provided. Individuals who were found to have intestinal worm infestation were provided with
deworming treatment at one of our collaborating health facilities near the study site. Those
found with other serious health conditions were referred to the nearest public health care
facility for further assessment and management. The study programme facilitated their
transport to the referral facility. Participants were encouraged to get their test results. Those
who wish to, were encouraged to return to designated health facility to receive their results.
The blood samples were taken by trained health professionals, using sterile equipment, thereby
minimizing any harm or risks to the study participants. A study participant who refused for
their samples to be taken were assumed not to have consented to participate in the study. All
data collected was stripped of identifiers and kept in password protected database only
accessible by the data manager and project principal and co-investigators.

To ensure the safety of researchers in the field, especially when working in areas on or close
to the dump sites, protective clothing was provided. These included a pair of sturdy gumboots,
face masks and protective coats. Protective gloves were provided to those taking the blood
samples.

Blood samples were stored for analysis in the future when more resources become available.
We therefore sought broad consent from all participants to cover any future analyses.

1.9 Data Processing and Analysis

Data coding, entry, and editing; transcription and coding of qualitative data generated

Quantitative data was collected using tablet computers programmed using Open Data Kit
(ODK). After data collection, data was uploaded on a safe APHRC server from where it was
extracted into analytical software. Further data management was conducted using Stata
software. Qualitative data was captured in digital recorders and transferred to computers. The
audio data were transcribed by a professional transcriber.

Analysis of quantitative and qualitative data

The quantitative data analysis were performed using STATA version 14.0. The analysis
involved descriptive analysis to provide general information on the characteristics of the
sample. The qualitative data was analyzed using NVivo. The data was synthesized using
thematic, content and narrative analyses and was triangulated with quantitative analysis results
to provide a robust picture of people’s perspectives on solid waste management and health
related risks arising from poor solid waste management practices.

Laboratory analysis

Laboratory analysis for blood and stool samples was conducted at the Kenya National Public
Health Laboratories Services (NPHLS). Upon reception of the specimen, the samples were
accessioned into the laboratory information system (LIMS). The sample was then taken to
respective section for analysis. Blood in EDTA tube was separated for plasma at the laboratory
by centrifugation and aliquoted into 2mls cryovials for storage at -80o C awaiting testing.
Plasma was analyzed for three biomarkers for hepatitis B; hepatitis B surface antigen (HBsAg),
hepatitis B surface antibodies (anti- HBs) and hepatitis B core antibody (anti-HBc) by the
enzyme linked immunosorbent assays (ELISA). The testing was done using bioelisa (BIOKIT,
S.A. - Ma s/n - 08186 Lliçà d’Amunt - Barcelona - Spain. Additionally, hemoglobin level of
study participants was measured using blood collected in the EDTA tube at the makeshift tent

10

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in the field using portable Hb meter. Stool samples was processed and examined by direct
smear method for the presence of protozoa using Kato- Katz quantitative technique for the
presence and count of parasites. For urinalysis, mid-stream urine sample was examined using
standard microscopy for pus cells and parasites.

1.10 Communicating Findings of the Study

The evidence generated was already being used to influence policy and action, specifically
promoting better waste management practices to reduce health risks associated with poor
SWM. We facilitated dialogue amongst SWM practitioners, community members, policy
makers and the general public on the need for better SWM to reduce the incidence of SWM
related diseases.

The project team worked with the key actors in the city to develop a strategic policy
engagement and communications plan, to guide the design and execution of actions that are
more likely to result in policy and programmatic decisions. Briefly outlined below are outreach
activities:

1. Communities at risk: These included key opinion leaders at the community level
including community health workers, administrative leaders, community elders, health
care providers, teachers, religious leaders and representatives of community-based
organizations.

2. Policy makers: These include Heads of Divisions and Programme Officers/managers in the
divisions of Environment, Health and Finance and Community Health Services, and
District/County Health Management Teams (DHMTs) for the Nairobi County using policy
briefs and face to face meetings. We shall also engaged the parliamentary committees on health
and environment in the county. At the regional level, we sought to engage the Eastern Central
Southern African- Health Committee (ECSA-HC) and the Network for parliamentary
committees of health, all of which have annual forums.

3. Practitioners, civil society and the research community: These include urban planners,
humanitarian agencies and research scientists both at the local and international levels. Building
on the fact that SWM is a devolved function under the 2010 Kenya constitution, we are part of
a countrywide Kenya Alliance of Residents Associations-led stakeholders’ forum that have
drafted model bills and policies on proper solid waste management across the counties of
Kenya. At the international level, we targeted participations at the World Health Summit,
United Nations Environmental Programme (UNEP) conferences and made presentations to a
global audience.

4. Public: We used a variety of channels to reach the general public including fact sheets, and
infographics. We also sought opportunities for interviews, news and opinion articles in the
national media, as well as social media. We specifically conducted a community feedback
meeting to share key results with community where most participants came from.

1.11. Study Limitations and Risks

Intense political activities around SWM in Nairobi is a key risk that hindered our study. To
address this risk, we collaborated with local groups to navigate the anticipated political
hindrances.

Mounting of mobile health post was misinterpreted by those working on the dump site and this
led to violent opposition and attacks and on field staff. To address this, we engaged the services
of community security guards throughout the data collection processes and called off further

11

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 data collection when the situation became very dangerous following the political violence of
the disputed Kenya’s general election in October 2017.

Beyond sampling solid waste workers using a systematic approach, the study was
constrained by resources and time. Otherwise it would have been necessary to sample
simultaneously non-waste workers as a comparative group to be able to establish that
findings among waste workers were peculiar to the group and wholly attributable to
exposure to poor solid waste management.

Our inclusion and exclusion criteria allowed only waste workers actively working in
the dumpsite during the period of the study. Those who were already sick, those down
and out and not able to work were not part of the study. Consequently, we may be
underestimating the implications of exposure to solid waste on loss to health.

In the context of lack of separation of wastes at source, waste workers are generally
exposed to hazardous chemicals, with well-known negative health outcomes such as
cancer, COPD, allergies and death. However, due to financial constraints, we were
unable to test for these outcomes as well as other infections like Hepatitis C and the
presence of heavy metals in the blood.

Notwithstanding, our work covered significant grounds that adequately contributes to

our understanding of the health risks associated with primary exposure to solid waste
in the city of Nairobi, which provides a veritable basis for local discourses and
engagement with policy makers in identifying health priorities and addressing related
risks and outcomes among the most vulnerable urban poor. The evidence contributes to
addressing the lack of data at local levels across African cities, which have been
identified as a major hindrance to answering questions critical to the health needs of the
urban poor; in addressing the great health inequities in urban areas; pinpointing
priorities; and improving urban health programming on the nature and distribution of
urban risks.

1.12 Operational definitions

1. Waste workers: refers to waste collectors/pickers, scavengers, and all those who offload
waste trucks at the Dandora dump site
2. Stakeholders: refer to waste management companies, community based organizations,
youth and women groups and community leaders

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