Feasibility assessment of improved hand and respiratory hygiene intervention in

elementary schools of Bangladesh

Farhana SultanaResearch Investigator

WASH Research GroupCentre for Communicable Diseases

Background

• Schools convene many susceptible people together

• They are efficient settings for the spread of gastrointestinal and respiratory diseases

• School-based hand and respiratory interventions have the potential to reduce disease transmission

• Limited infrastructure, funds and maintenance systems to support hygiene practices in Bangladesh

(Ref: Neuzil K.M. et al 2002, Stebbins S. et al 2009, Adams J. et al 2009, Xue Y. et al 2012, Freeman M.C. et al 2012, Nasreen S. et al 2010, Nizame F.A. 2011)

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Hand hygiene interventions tested to date

• Handwashing with different cleaning agents at important key times

• Worldwide school-based hand hygiene interventions:

Tippy taps Super jaboncín SanitizerSoapy water

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Photo credit: www.flickr.com, www.wsp.org, Amy J. Pickering, CARE/Brendan Bannon

Recommended respiratory hygiene intervention

(Ref: CDC, 2013, Barry, T., et al. 2011) 4

Recommended respiratory hygiene intervention

• In high income countries:• Use of tissue/handkerchief

observed 3.4% • Covering with elbow/arm

observed 1.3%

• Into open air 85% in Bangladesh

• Lack of evidence and application in low-income countries

(Ref: CDC, 2013, Barry, T., et al. 2011) 5

Objectives

• To pilot an intervention that encourages school children to:

- wash hands with soapy water at three key times- use upper sleeves for coughing and sneezing

• To evaluate the uptake of targeted practices

• To assess the feasibility and acceptability of the intervention

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Methods

• Sample size: 2 urban and 2 rural elementary schools

• Study sites: urban Dhaka and rural Mymensingh

• Target population: school children aged 5-13 yrs

• Study period: May 2011- September 2013

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Intervention design

• Training teachers to lead hygiene classes

• Provision of handwashing stations and behavior change communication materials

• Formation of a hygiene committee to:- cover cost of soapy water - maintain handwashing stations- promote regular hand and

respiratory hygiene practices

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Handwashing station

40L reservoir with tap

Soapy water bottle with metal holder

Stand

16L bucket to collect rinse water

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Soapy water preparation method

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Handwashing at recommended key times

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Coughing and sneezing into upper sleeves

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Data collection techniques

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Baseline

Spot checks of facilities

(4)

Data collection techniques

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Baseline During 1 month follow-

up after intervention

began

Spot checks of facilities

(4)

Spot checks of facilities

(24)

Structured observations

(24)

Data collection techniques

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Baseline During 1 month follow-

up after intervention

began

2 months post-

intervention

Spot checks of facilities

(4)

Spot checks of facilities

(24)

Pocket voting (96)

Structured observations

(24)

Focus group discussions

(13)In-depth

interviews (5)

Data collection techniques

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Baseline During 1 month follow-

up after intervention

began

2 months post-

intervention

No visits by study team Spot

checks of facilities

(4)

Spot checks of facilities

(24)

Pocket voting (96)

Structured observations

(24)

Focus group discussions

(13)In-depth

interviews (5)

Data collection techniques

17

Baseline During 1 month follow-

up after intervention

began

2 months post-

intervention

No visits by study team

14 months post-

intervention

Spot checks of facilities

(4)

Spot checks of facilities

(24)

Pocket voting (96)

Spot checks of facilities (4)

Structured observations

(24)

Focus group discussions

(13)

Focus group discussions

(14)In-depth

interviews (5)In-depth

interviews (2)

Data collection techniques

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Pocket voting exercise with students Focus group discussion with teachers and school committee members

School physical environment

Characteristics Urban Urban Rural Rural

Govt. School (1)

Non-Govt. School

(2)

Govt. School (1)

Non-Govt. School (2)

# of students 1089 640 468 335Available toilets 4 1 1 1Handwashing water source

Piped water

supply

Deep tube-well

Shallow tube-well

Shallow tube-well

Hand cleansing material at handwashing place before intervention began

No No No No

During 1 month follow-up

Yes Yes Yes Yes

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Observed and reported practices (1 month follow-up)

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Using upper sleeves

Before eating

After toileting

After cleaning toilet

0 10 20 30 40 50 60 70 80 90 100

Observed Reported

Subjective, personal and descriptive norm factors

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Descriptive norms

Personal norms

Subjective norms

0 10 20 30 40 50 60 70 80 90 100

Respiratory hygiene Hand hygiene

Reported knowledge about disease transmission

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Respiratory diseases

Diarrhea

0 20 40 60 80 100

Perceived benefits

• Handwashing station was:- attractive and child friendly - worked as reminder for handwashing - low-cost- a complete technology with soap and water

• Both health and non-health benefits motivated students to wash hands

“Washing hands with soapy water causes germ free hands.” (One female student of grade IV at a rural school)

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• Using upper sleeves perceived as: - an innovative idea- easy to comply - did not require cost or maintenance

• Injunctive norms (teachers and peer expectations) motivated students to use upper sleeves

“It is a new and easy method of coughing and sneezing that helps me and my friends to remain germ-free.” (One female student of grade V at a rural school)

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Perceived benefits

• Formation of hygiene committee institutionalized the intervention:

- Teachers conducted hygiene classes, covered detergent cost along with committee members

- Teachers and students encouraged habit formation, and disseminated information to the community

- Students and janitors maintained handwashing station

“We refill water and prepare soapy water just after arriving at school otherwise students will not be able to wash hands.” (male student of grade V at a rural school)

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Perceived benefits

Perceived barriers

• Sometimes the pump of soapy water bottle was stuck

• Rural school students sometimes missed classes for maintenance

• Some students did not wash hands/use upper sleeves because:

- they were in a hurry to play or go to class- they had not become habituated

“The pump needs frequent pressing to get soapy water.” (One male student of grade IV at a rural school )

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Observed hand and respiratory hygiene practices (14 month follow-up)

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Using upper sleeves

Before eating

After toileting

After cleaning toilet

0 20 40 60 80 100

Qualitative findings (14 month follow-up)

• Urban schools stopped using handwashing stations due to lack of maintenance

• Rural schools continued using handwashing stations:- high perceived benefits - active hygiene committee- involvement of students

• Using upper sleeves:- new behavior to adopt and sustain - regular promotion required

“Sometime I also cough/sneeze into open air during my classes due to childhood habit, therefore, it is difficult to expect students to remember using upper sleeves.” (One female teacher at a rural school)

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Conclusion

• The intervention was acceptable and feasible among school community:

- using upper sleeves did not require tissues/water/ soap/maintenance

- recurring cost for soapy water was low

• Schools covered costs after project ended suggestive of sustainability and scalability

• Short intervention was insufficient to achieve longer-term habit adoption

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Recommendations• Involve education ministry to promote hygiene

interventions in schools for sustainability

• Hygiene committee may appoint and cover the salary of a janitor or provide incentives to students

• Need to develop and evaluate strategies for sustained habit adoption

• Further research needed to assess:- scalability and sustainability of the intervention- longer term adoption of habits- impact on health and school attendance

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AcknowledgementsFunding

USAID Stanford University

Stephen P. LubyJHSPH

Peter J. Winch Primary Education Division, Dhaka

Kawsar SabinaSchool community

TeachersStudentsCommittee membersJanitors

icddr,bLeanne E. UnicombDorothy L. SouthernFosiul A. Nizame Nadira Sultana Kakoly Md. Mahadi HasanMd. Mizanur RahmanShima SultanaHumayun KabirAnupama Islam NishoKishor K. DasCarrie Read

For correspondence: farhana.sultana@icddrb.org

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