FORMATIVE AND BASELINE SURVEY ON HANDWAHSING WITH … - Formative... · FORMATIVE AND BASELINE...

F O R M AT I V E A N D B A S E L I N E S U R V E Y O N

H A N D WA H S I N G W I T H S O A P

F I N A L RE P O RT

Prepared for

WSP-Water and Sanitation Programme

Prepared By:

The Steadman Group Buganda Road, Plot 63

Nakasero, Kampala P.O. Box 21571,

Tel: +256 – 41 – 237990 /9 Fax: +256 – 41 – 347195

Kampala, Uganda E-mail: [email protected]

Technical support: Hygiene Centre, London School of Hygiene and Tropical Medicine

January 2007

Social Research Division

mailto:[email protected]

Prepared for: WSP – Water and Sanitation Programme

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(i)Acknowledgement The Steadman Group (U) Ltd is grateful to all those collaborators, stakeholders and consultants who provided invaluable input that has enabled the successful conclusion of the Handwashing Baseline and Formative research. Tribute goes to the World Bank team, the London School of Hygiene and Tropical Medicine (Val Curtis & Bob Aunger), UWASNET, Uneliver London (Helen Travaski & Myriam Sidibe) M/s Kellen Namusisi and Rujumba Joseph (Steadman Consultants). The Steadman Group (U) Ltd also extends gratitude to their staff for the tireless effort put into the successful completion of the work.


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(ii)Executive Summary Although handwashing with soap is recognized as a major way of preventing diarrhea diseases by up to 50% (Curtis 2003) and Acute Respiratory Infections (ARI) by about a quarter (Rabie 2006) it has remained low particularly handwashing with soap.

Although a number of small-scale interventions have been undertaken in Uganda in the past, there is no reliable data on handwashing practices, nor has there been understanding of the reasons why people do or do not wash their hands with soap mainly because hand washing behavior is an emotive issue.

The National Sanitation Working Group (NSWG) intends to design and execute a national handwashing with soap campaign aimed at increasing the rates of handwashing with soap at key junctures among the groups most susceptible to diarrhoeal diseases: 1) children less than five years of age through their caretakers and 2) school-aged children (6-13 years). To this effect the NSWG, with support from WSP commissioned a research (baseline and formative) to provide information to be used in the design of a national handwashing with soap campaign.

The main purpose of this research was to provide insights to the design of an effective communication programme to promote hand washing with soap. The specific objectives were to;

1. Document current hand washing practices and their context 2. Establish factors that drive and facilitate hand washing in communities 3. Identify target audiences for the campaign 4. Determine the current channels of communication used in the community.

Methods The research utilized both qualitative and quantitative methods of data collection and was executed at two levels; community and school targeting caregivers of children under 5 years and school going children of 6-13 years. The community methods included: 1. Structured Observations which involved observation of handwashing behaviour with or without soap

during key junctures of: after contact with faeces and before handling food/eating in households. This was carried out in 10 districts and covered a total of 500 observations.

2. Behavioural Trials: this involved introducing caregivers of children under 5 years to the behaviour of HWWS, and later assessed their experiences. A total of 20 trials were carried out in 5 districts.

3. Focus Group Discussions: These focused on motivators and barriers of handwashing with soap at key junctures and were carried out with both male and female caregivers of children under 5 years. A total of 7 FGDs were conducted in 5 districts.

4. In-Depth Interviews: These were conducted with influential people in the communities of study and a total of 12 were carried out in 5 districts.

Since children of age 6 to 13years spend much of their day in school, it was decided to study children in the school setting. The methods used in schools included: 1. Structured observations: This involved observation of handwashing behaviour among school going

children in 4 schools drawn from 4 districts. 2. Behaviour trials: This involved exposing pupils to handwashing with soap within the school context

and later assessed. 3. ‘Hygiene detective’ This involved using pupils as hygiene detectives to identify risky handwashing

behaviour among pupils in school. In each of the four schools 4 detectives were identified 4. Money game: This was intended to identify what is of value and interest to the children. It involved

giving the children a photocopy of a note of money and asking them what they would use it for. 5. Diary: This was intended to get an overview of a typical child’s day. 6. Teacher focus group discussions and In-depth interviews to assess the teachers’ opinions on the

campaign.


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RESULTS Current handwashing practices

• Although 84% of the adults recognized the need to wash hands with soap after using the toilet, only 14% were observed to do so. Overall 57% washed their hands in some way.

• Of the caregivers observed, 19% washed hands with soap after cleaning a baby’s bottom. Overall 35% washed their hands in some way.

• Although more caregivers washed their hands before eating, (60% all together), only 8% used soap.

• From the school observations, 54% of the pupils washed their hands after using the toilet. Only 5% used soap.

• Handwashing is low priority for the use of soap, below laundry, washing dishes and bathing. • Overall 95% of the households have used soap • Most people know that it is important to HWWS, but few people practice it.

Motivators for handwashing

• Disgust at having dirty hands especially after the toilet emerged as the strongest motivator for handwashing

• Those who participated in the BTs showed real enthusiasm for the pleasures of having clean hands and the comfort of removing stickiness and having clean hands

• There was a strong desire to conform with what others do • There was a strong view that HWWS is the ‘right’ or moral thing to do (84% felt so) • Nurturing a child emerged as a less important motivator for handwashing as it conflicted with a

need to offer spontaneous love • Though handwashing offered safety from illness, the concern was not for child diarrhea but for

life-threatening cholera. • Handwashing is a habitual behavior, occurring to specific cues, e.g. before eating. The use of

soap needs to become ‘automatically’ connected to HW and to cues such as leaving the toilet Factors that drive and facilitate handwashing The study sought to establish barriers and motivators to handwashing with soap in homes and results show that there were physical, biological, cognitive, and socio-economic barriers. Some of these barriers can be alleviated. Physical Barriers to HWWS included: convenience in relation to handwashing facility and availability of soap near by; amount of time spent on handwashing especially where people are busy and there are too many junctures for handwashing; and availability of water for handwashing. Biological barriers: these included: forgetfulness of people due to slow adaptation to a new behaviour and the many junctures for handwashing. Other biological barriers were; fatigue in relation to the many junctures of handwashing as well as sensory barriers where soap was reported to affect the taste of food. Cognitive barriers included: uuncertainty of the relative risk of diarrhoea to mortality and morbidity, fear of unknown hence resist change and strong cultural beliefs such as not hand washing to care for children also hindered HWWS. Socio-economic barriers included poverty; where the cost of soap was perceived to be high. This was also reported to be hinder sustainability of the HWWS behaviour. HWWS was further perceived to be for ‘Civilized’ people who are better off people and educated hence not for the lay person in the rural areas (‘not for us’). Other socio-economic barriers were politicians who were reported to compromise the work of technocrats in hygiene and sanitation such as Health Assistants and negative attitudes of health workers towards the community, where communities are looked upon as primitive and therefore can’t adapt to new health programmes such as HWWS.


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In schools, barriers included:

• lack of handwashing facilities, • soap being too expensive and therefore tends not to be available in schools, • lack of water • lack of time for everyone to wash hands during breaks, • teachers don’t emphasize the importance of handwashing with soap

In schools, compliance with handwashing is motivated by the fact that soap is believed to kill germs and prevent diseases. Current Channels of communication Overall the most commonly used sources of information at community level were: radio mainly because it is easily accessed by many; community meetings because these are attended by many people; community leaders because they are trusted and part of the community and workshops/seminars because many people are involved including those from out side the community. In rural areas, children’s access to media is often limited to radio programmes. In urban areas, they have greater access to TV. CONCLUSIONS

• Handwashing with soap at critical junctures is not a common practice in Uganda, either in the general community, nor in schools, despite a history of promotional activities around sanitation, water and hygiene.

• Soap and water availability are key facilitators to HWWS. Many households already keep soap at centrally located places such as drying racks facilities that cab be adapted to handwashing.

• The levels of handwashing with soap for children (6-13 years) after defecation at home is lower than at school which suggests that the school environment facilitates hygiene behaviour, possibly due to constant reminders and peer influence

• It is possible that making handwashing a priority will be difficult because communities significantly fear HIV/AIDS and malaria that are believed to cause death compared to diarrhoeal diseases.

RECOMMENDATIONS

• Reaching school-children through communication should be through radio messages in the evening when they have free time and are at home.

• Radio is the most important form of mass media for mothers, however, it will need saturation coverage and a very distinctive approach if it is to make a difference

• The campaign will have to have a strong ‘buzz factor’ in other words it must be so surprising, intriguing, unusual or attention-grabbing that everybody will pay attention to it.

• Since health workers are regarded as being disdainful, they may not be the best vehicles of hand washing messages in communities

• Linking the campaign to epidemics like cholera will be unsustainable because once the epidemic has gone so will the practice of handwashing.

• The campaign should ensure to involve teachers and children in school handwashing programme, e.g., by giving them specialized tools and materials that excite them.

• Ugandans are quite religious and have high cultural emphasis on being good and cooperative. This set of beliefs can be used to advance and support the campaign.


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(iii)Glossary AIDS Acquired Immuno Deficiency Syndrome ARI Acute Respiratory Infections AMREF African Medical Research Foundation BT Behaviour Trails CARE Carry America Relief Every where CBO Community Based Organization CIA Central Intelligence Agency ECWSP Eastern Centres Water and Sanitation Programme FGD Focus Group Discussions GTZ German Technical Cooperation HIV Human Immunodeficiency Virus HWWS or WHWS Handwashing With Soap or Washing Hands With Soap IDI In-depth Interviews IMR Infant Mortality Rate LC Local Council NGO Non-Governmental Organization PEAP Poverty Eradication Action Plan RUWASA Rural Water & Sanitation Programme TV Television UAMPS Uganda All Media and Product Survey UBOS Uganda Bureau Of Statistics UDHS Uganda Demographic Health Survey UHPC Uganda Housing & Population Census UNICEF United Nations Children’s Fund SES Social Economic Status WES Water & Environmental Sanitation WHO World Health Organization


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TABLE OF CONTENTS (i)Acknowledgement ........................................................................................................................ ii (ii)Executive Summary ................................................................................................................... iii (iii)Glossary...................................................................................................................................... vi (iv) LIST OF TABLES.............................................................................................................. ix (v) LIST OF FIGURES............................................................................................................. x SECTION ONE: Introduction ........................................................................................................ 1

1.0 Justification............................................................................................................................. 1 1.1 Objectives of the national handwashing campaign.............................................................. 1 1.3 Objectives of the formative research ................................................................................... 1

2.0 Background on Uganda......................................................................................................... 3

2.1 General information on Uganda........................................................................................... 3 2.2 Background on study districts.............................................................................................. 5 2.3 History of Hygiene Interventions......................................................................................... 5 2.4 Private sector intervention: the soap market ........................................................................ 6

3.0 Methods used in the Community Study............................................................................... 8

3.1 Desk Research...................................................................................................................... 8 3.2 Field Methods ...................................................................................................................... 8

4.0 Results ................................................................................................................................... 11

4.1 Baseline data on handwashing behaviour (‘what’) ............................................................ 11 4.2 Target Audience (‘Who’)................................................................................................... 12 4.3 Barriers and motivators to handwashing with soap (‘Why?’) ........................................... 14 4.4 Communications for behaviour change (‘How’) ............................................................... 27

SECTION THREE: The Schools Study....................................................................................... 29

5.0 Introduction.......................................................................................................................... 29 5.1 Objectives .......................................................................................................................... 29 5.2 Background on schools ...................................................................................................... 29

6.0 Methods................................................................................................................................. 29

6.1. Selection and description of schools for study ................................................................. 29 6.2. Overview of methods........................................................................................................ 30 6.3 Behaviour trials.................................................................................................................. 31

7.0 Results ................................................................................................................................... 33

7.1. Baseline behaviours of children in school (‘What’) ......................................................... 33 7.2 The school environment for hygiene ................................................................................. 36 7.3. Children as people (‘Who’) .............................................................................................. 36 7.4. Why children might wash hands with soap (‘Why’) ........................................................ 37 7.5. How to get children to wash hands with soap?................................................................. 39

SECTION FOUR: Conclusions .................................................................................................... 42

8.0 Conclusions ........................................................................................................................... 42 8.1 What we have learned........................................................................................................ 42 8.2 Major challenges ......................................................................................................... 44

SECTION FIVE: Recommendations ........................................................................................... 45


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APPENDICES ................................................................................................................................ 46

Annex 1: Illustrations for used in FGDs .................................................................................. 46 Annex 2: Materials used in Schools.......................................................................................... 48 Annex 3: Data collection Instruments ...................................................................................... 50


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(iv) LIST OF TABLES Tables Page Table 2.1: Major population indicators on health, education, water and sanitation in Uganda Table 2.2: Information about districts under study Table 2.3: Brands and Cost in Kampala retail for bar and toilet soap Table 2.4: Leading toilet soap brands (Unilever 2006) Table 3.1: Summary of study methods Table 4.1: Hand washing with and without soap by primary child care giver Table 4.2: Characteristics of study participants Table 4.3: Dreams of Mothers Table 4.4: Barriers and Biggest fears to Realisation of Dreams Table 4.5: Motivating factors Table 4.6: FGD quotes about disgust and HW Table 4.7: FGD quotes about Purity and HW Table 4.8: FGD quotes about Comfort and HW Table 4.9: FGD quotes about Status and HW Table 4.10: FGD quotes about attraction and HW Table 4.11: FGD quotes about nurture and HW Table 4.12: FGD quotes about conformity and HW Table 4.13: Quotes about safety and HW Table 4.14: Quotes about habit Table 4.15: Individual rankings of HW motivations by female FGD participants Table 4.16: Injunctive norms when are the key times you must wash hands with soap Table 4.17: Environmental determinants of primary care giver being a soap user for HW Table 4.18: Psychosocial determinants of being a soap user Table 4.19: Barriers to hand washing with soap Table 4.20: Quotes on facilitators of memory for HWWS Table 4.21: Quotes on sensory benefits to soap Table 4.22: Channels of Communication at community level Table 6.2: School-based study methods Table 7.1: Handwashing behaviours in school Table 7.2: Handwashing after defecation by School Aged children at Community and in Schools Table 7.3: Photos/Drawings of Hygiene Behaviours Table 7.4: Likes and Dislikes of Children on Practicing HWWS by District Table: 7.5: Drivers to Handwashing in Schools during the BT Table: 7.6: Barriers to HWWS- Lessons from BT in Schools Table 7.7: Advantages of the new behaviours Table 7.8: Showing the three most expensive items per pupil in the money game Table 7.9: Cool and Smart Table 7.10: Gender and Age Table 9.1: Recommendations for the HWWS campaign Table 9.2: Ten great ideas to get moms to wash hands with soap Table 9.3: A few great ideas to get children to wash hands with soap


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(v) LIST OF FIGURES Table Page Figure1: Map of Uganda Figure 2: Pupil washed hands without soap yet the soap was available Figure 3: A boy leaves the latrine without washing hands Figure 4: A pupil washes hands after the latrine but does not use soap Figure 5: Primary 6 Pupil urinating near the tree Figure 6: Girl rinses her mouth, while others wait to wash their hands after using the latrine Figure 7: A girl washes hands after using the latrine Figure: 8: A girl washes her hands without soap after using the latrine Figure 9: A group of boys washing hands without soap


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SECTION ONE: Introduction

1.0 Justification Hand washing with soap is recognized as a major way of preventing diarrhea diseases. It has been referred to as the “do-it-yourself” vaccination, since studies have shown that it can reduce the incidence of diarrhea by up to 50% (Curtis 2003) and that of Acute Respiratory Infections (ARI) by about a quarter (Rabie 2006) However, hand washing, especially with soap, remains low.

The National Sanitation Working Group and the Water and Sanitation Programme recognizes that it is critical to improve the health and reduce incidence of diarrheal diseases and acute respiratory infections (ARI) among populations at risk through private-public partnerships by encouraging hand washing with soap.

A number of small-scale interventions have been undertaken in Uganda in the past and though these have had an impact, they do not readily scale to a national level. Information on current hand washing levels is hard to find because hand washing behavior is an emotive issue-making it hard to collect valid data about actual practice through questionnaire-based surveys. We do not therefore have reliable data on handwashing practices in Uganda. Nor do we understand the reasons why people do or do not wash their hands with soap. Past sanitation activities in the country have mainly focused on provision of clean water and sanitation facilities, good water storage methods and water treatment. Hand washing with soap as a preventive sanitation measure against diarrheal diseases has not been a particular focus of attention. The National Sanitation Working Group intends to design, implement and monitor a national handwashing campaign program for Uganda.

1.1 Objectives of the national handwashing campaign

The aim of the National Hand Washing Program is to double the level of hand washing with soap at key junctures such as after using the toilet, before feeding babies or eating and after cleaning the child’s bottom over two years. The campaign will target caregivers of children below 5 years and children between 6-13 years.

This plan will be achieved by uniting the efforts of stakeholders, at international, national and local level. Partners include the Government of Uganda (including Ministry of Health, Ministry of Water and Environment and Ministry of Education and Sport, and politicians and Uganda Water and Sanitation Network); local partners including Uganda Water and Sanitation Network membership, local governments, Parish Development Committees, Community Based Organizations working in the area of water and sanitation, members of the National Sanitation Working Group and development partners such as DANIDA, UNICEF and GTZ. In the private sector, partners include: Mukwano Soap Industries, Unilever Uganda Ltd and others. The formative research reported on here was commissioned so as to provide the information needed to design the National Handwashing campaign.

1.3 Objectives of the formative research

The main purpose of the research is to provide insights to be used to design an effective communication programme to promote hand washing with soap. The survey findings will enable the partners to develop an appropriate hand washing campaign and provide a baseline against which behavioral change during and after the national hand washing campaign will be measured.

Specifically the survey will seek to: 1. Document the current hand washing practices and their context 2. Characterise target audiences for the campaign 3. Establish factors that drive and facilitate hand washing in communities 4. Understand the current channels of communication used in the community.


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The current report on the formative research in support of the Uganda campaign is divided into three sections. The first reports on studies focused on communities in which women with children live, the second on a study of school-aged children, while a concluding section provides suggestions for the design of the handwashing campaign.


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2.0 Background on Uganda

2.1 General information on Uganda This chapter describes the geography, demographic and socio-economic characteristics of Uganda, including indicators such as; age composition and population distributions, education, health in particular indicators on the under 5s, education, sanitation and hygiene. Table 2.1: Major population indicators on health, education, water and sanitation in Uganda Indicator Uganda Population 26.8M (12% urban) % of population below poverty line 37.7% IMR 132/1000 (UDHS) Under 5 mortality 152/1000 (UDHS) 138/1000 (WHO) Latrine coverage 58% (MoWEE); 79% (DHS) 83%; (UHPC, 2002) Access to clean water 61% Rural; 51% Urban Life expectancy 49 (51 female; 48 male) Literacy 64% (54% females; 75% males) TFR 6.7 Uganda is one of the poorest countries in Sub-Saharan Africa with an Annual Gross Domestic Product per capita of $1,800, a debt of 29% of GDP (CIA) and a growth rate of 5% per annum with considerable variations in wealth between its regions, the northern being the poorest with 64% of the people there living below poverty line. Uganda has a high population growth rate of 3.3% and Total Fertility Rate of 6.7 (the highest in East Africa) which is not proportionate to the economic growth (UDHS, 2000). The Housing and Population Census, 2002 indicates that Uganda has a fairly young population with a big under 15 years 49%, under 5 years 19%, while those over 60 years of age constitute 7%. The country has been badly affected by the HIV pandemic with current prevalence of 6.5% (reported to have gone higher to 8%) and about 2 million people living with HIV/AIDS. Officially some 900,000 have died of HIV/AIDS (UAC, 2005) The ethnic makeup is as follows: Baganda 17%, Ankole 8%, Basoga 8%, Iteso 8%, Bakiga 7%, Langi 6%, Rwanda 6%, Bagisu 5%, Acholi 4%, Lugbara 4%, Batoro 3%, Bunyoro 3%, Alur 2%, Bagwere 2%, Bakonjo 2%, Jopodhola 2%, Karamojong 2%, Rundi 2%, non-African (European, Asian, Arab) 1%, other 8% (CIA). The leading causes of under-five mortality are malaria 23%, pneumonia (21), and diarrhoea (17%), where the overall two week prevalence of diarrhoea under fives in Uganda is 20% (MoH 2005), although it’s higher in the East and Northern regions. [WHO, 2006 Health Indicators in Uganda] Over 71% of people are engaged in subsistence agriculture and only 7% and 9% engaged in professional work and service industries respectively.


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Figure 1: Map of Uganda


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2.2 Background on study districts 10 districts were selected for the study from the 4 regions of Uganda. Table 2.2 gives a description of the study districts, particularly the climate, population size, language, education and health indicators (UHPC, 2002)

Table 2.2: Information about districts under study REGION Sample

District Climate Population Language Education Health

Bushenyi High rainfall, 25C average, grass lowland

736K (14K urban)

Runyankole 430 primary schools, 40 secondary, 8 tertiary

2 hospitals, 42 health centres

Masindi low, savannah, medium rain, grassy

261K (14K urban)

Runyoro 148 primary, 12 second, 2 tertiary

1 hospital, 14 HCs

Western

Kabale medium rain, forest/shrub

417K (29K urban)

Rukiga, Kinyarwanda

274 primary, 29 secondary, 4 tertiary

1 hospital, 31 health centres

Northern Lira High altitude, medium rainfall, high temperature

501K (28K urban)

Lwo 313 primary, 28 secondary, 6 tertiary

1 hospital

Mpigi Heavy rains, high temp

613K Luganda 356 primary, 117 secondary, 5 tertiary


Kampala equatorial, high rainfall, high temperature

774K (all urban)

Luganda, English, Swahili, others

308 primary, 36 secondary, 3 tertiary

7 hospitals

Central

Kiboga Moderate rain/temp 141K (5K urban)

Luganda 114 primary, 6 secondary


Mayuge high altitude, medium rainfall, high temperature

217K Lusoga 111 primary, 16 secondary, no tertiary

1 hospital, 7 health units

Mbale high, high rain, forests, sub-tropical climate

745K Lumasaba 330 primary, 58 secondary, 5 tertiary


Eastern

Iganga Minimum rain, 691K Lusoga 362 primary, 79 secondary, 2 tertiary


Among the study districts, apart from Kampala, Bushenyi district in the west is one of the wealthiest in the country and is usually referred to as ‘a model district’ which has received many development activities, including in water supply and sanitation. Lira in northern Uganda is least wealthy of all and is in the northern part of the country which has suffered civil war for the last 20 years. Kampala located in central is the capital city, although the study participants were drawn from slums which house the urban poor with poor indicators on sanitation and hygiene. The rest of the districts have similar characteristics with not much difference as indicated in table 2.2.

2.3 History of Hygiene Interventions The Government of Uganda identified Hygiene Promotion and Sanitation (HP&S) as one of the key issues necessary for development, particularly in addressing the unacceptably high Infant and Maternal Mortality Rates. This is reflected in the increased policy attention to environmental sanitation reflected in the revised PEAP. In the past, hygiene promotion has been addressed through donor funded initiatives such as RUWASA, SWIP, WES, ECWSP and other NGO sponsored approaches. In most of these programmes priority was given to the construction of water facilities, although some carried out hygiene promotion of the beneficiary communities. Most local governments have not prioritized hygiene and sanitation which remain largely unfunded.


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The RUWASA project covered 15 districts of eastern Uganda, including 3 of the study districts of Iganga, Mayuge and Mbale, from 1990 to 2000. The project carried out community mobilisation for household latrine construction, maintenance and handwashing. The ECWSP, also funded by DANIDA, covered 11 towns in eastern Uganda, two of them in the districts of Iganga and Mbale. The project provided latrine facilities in all schools in the towns and carried out hygiene promotion, including handwashing, of the students, teachers and communities in the towns. The WES project covered all the districts which were not covered by the RUWASA project, including Kiboga, Mpigi, Bushenyi, Masindi, Kabala and Lira. WES project constructed latrines and handwashing facilities in primary schools, formed health clubs and trained science teachers in good hygiene and sanitation practice. UNICEF programme has constructed latrines in primary schools and provided rainwater harvesting tanks and handwashing facilities in selected districts including Lira. In addition it assisted formation of health clubs, child rights clubs and girl education movement clubs, all of which have an integrated approach including hygiene promotion. In addition to what has been carried out under the projects, several NGOs have had hygiene promotion campaigns in different districts in Uganda. Hygiene promotion was carried out in Mpigi by World Vision. It was also reported that students of Nsamizi Training Institute carried out hygiene promotion in the study area in Mpigi district. Water Aid Uganda facilitated Masindi district to carry out hygiene promotion, while AMREF worked in Kabale district. In Kampala, Plan Uganda has worked in Kawempe division, one of the study areas. CBOs and smaller NGOs have also had hygiene promotion campaigns in selected sub-counties or villages, although these are largely unreported.

2.4 Private sector intervention: the soap market The availability of soap is a primary determinant of handwashing behaviour. We therefore summarise the state of the soap market in Uganda. Soap is generally available throughout Uganda. In our survey 95% of the respondents had some kind of soap present in their households. There are two major types of soap: perfumed toilet soaps and laundry bars (600-700g bars in brown/blue/white). Other cleansing agents include detergents such as Omo imported from Kenya, Nomi made by Mukwano soap industries, Gental made by Bidco Industries and Jireh liquid soap made by Sameg Shemical Products. A few locally made soaps some herbal in nature, like Samona and Movit are produced in Kampala and distributed. Some of these small manufacturers produce soap for babies (baby soap); Samona herbal soap and Mwana Mugimu. Household production is very limited in Uganda, restricted to a few local cooperatives producing floor cleaning agents (liquid soap). The soap market in Uganda has got both locally manufactured brands and numerous imported brands. Among the local manufacturing concerns the leading companies are Mukwano industries, Unilever Uganda and Bidco. Distribution networks are a limiting factor for the penetration of different types of soap. Hence for example Chapa Nyota has over 70% of the laundry soap market largely because they have the best distribution network throughout the country. The Bar soap market size is 120,000 tons per year with a value of about US Dollars 53,040,000. The toilet soap market size is 5,904 tons annually with a value of US Dollars 12, 937,845. (Unilever, 2006). Bar soap usage is thus 20 times bigger than toilet soap, but its total value is only 4 time higher.


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Table 2.3: Brands and Cost in Kampala retail for bar and toilet soap No: Brand Weight

In Grams

Cost / Bar (UG. Shs)

Cost / Piece (UG. Shs)

Manufacturer

Bar Soaps 1 Star – Chapa Nyota 700 1,000 250 Mukwano 2 Bull 600 1,000 200 Bidco 3 Ngoma 600 800 100 Unilever 4 Key 600 800 100 Unilever 5 Chapa Mukwano 700 900 200 Mukwano 6 Safi 700 800 100 Madhivani

Toilet Soaps 1 Geisha 225 1,000 Unilever 2 Protex 100 1,000 Colgate Palmolive

120 1,500 Samona Products 90 1,000 Samona Products

3 Samona

35 500 Samona Products 4 Dettol 100 1,000 Reckitt

180 1,000 Unilever 5 Lifebuoy 150 500 Unilever

6 Movit 100 1,000 Movit Products Note: In rural areas laundry bar soap is what is most commonly used for all purposes. It is often bought in pieces cut from 600g or 700g bars-each piece sells for 100-250UG.SHS. (I.e. it costs several times more to buy by the piece). Toilet soap is not common in the rural areas but generally the brands on the market include; Yeyo, Mekako, Jaribu, Imperial Leather, Rexona, Dove, Fa and Lux. An annual average of US Dollars 386,740 is spent on media promotion of toilet soap Table 2.4: Leading toilet soap brands (Unilever 2006) Type % Protex 15% Dettol 12% Samona 9% Yeyo 1% Mean monthly household expenditure on bar soap is 1,843UG.SHS and toilet soap is 1,339 UG.SHS which represents about 4% of total expenditure (Uganda National Housing survey 2003).


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SECTION TWO: The Community Study The community study was designed to understand hand washing behaviour using both quantitative and qualitative methods. In this section we present the methods and results of the community study. Section three presents the schools study. The studies were designed by WSP with assistance from the LSHTM and Unilever. The Steadman Group field tested the instruments and adapted them to the national context The Steadman group also conducted and supervised the fieldwork process with assistance from WSP. The Steadman Group analysed the data and reported the work with assistance from the LSHTM and WSP. The studies were carried out in the period of 5 months (22weeks)

3.0 Methods used in the Community Study

3.1 Desk Research Desk research was undertaken to document background information on factors that would impact on hand washing with soap. The sources of information were; programme, policy documents and research reports on hygiene and sanitation situation in Uganda; population and livelihood indicators and media monitoring surveys. The desk research generated the following information: general information on Uganda such as the geography of the areas, infrastructure, socio-cultural, industries and economic factors. The review also carried out a media analysis capturing usage of various formal media i.e. print, electronic media i.e. radio and television among others. The reach and coverage of various electronic media i.e. radio and TV; circulation volumes of key print magazines and the approximate readership quotient; Hygiene and sanitation situation in Uganda i.e. toilet facilities by region, access to clean water by region and health situation in Uganda with specific focus on diarrhoea and ARI diseases, leading causes of less than 5 mortality etc.

3.2 Field Methods Four methods were used to gather data from the field. The methods are summarised in Table 3.1. Table 3.1: Summary of study methods

Method Target population Sample size Study districts Structured Observations & interview

Care givers of <5yrs 500 (50 per district)

10 (Kampala, Iganga, Mayuge, Mpigi, Lira, Bushenyi, Masindi, Kiboga, Mbale and Kabale

Behavioural Trials Primary Care givers of < 5yrs

20 5 (Kiboga, Mayuge, Lira Bushenyi and Kampala)

Focus Group Discussions Care givers of <5yrs both male and female

7(5 female & 2 Male)

5 ((Kiboga, Mayuge, Lira Bushenyi and Kampala)

In-Depth Interviews Community leaders 12 5 (Kiboga, Mayuge, Lira Bushenyi and Kampala)

Study Instruments are attached as Annex 3

3.2.1 Structured Observations The quantitative research in communities employed structured observations (SO) followed by a household survey (HS). This involved observation of handwashing behaviour with or without soap during key moments of: after contact with faeces and before handling food/eating in households. The objectives of this method were to establish the proportion of times:

1. Mothers wash hands with soap (WHWS) after using the toilet 2. Mothers WHWS after cleaning up index child 3. Mothers WHWS before feeding a child 4. Mothers WHWS before handling foods (taken raw) 5. School age children WHWS after the toilet at home


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Structured observations were conducted in 10 districts representing the four regions of Uganda and were selected using the probability proportion to size (PPS) method to select the districts such that the region with more districts had a higher number of districts selected. At the regional level, the study districts were selected randomly. In each of the districts five clusters were selected randomly from which 10 observations were conducted.

Sampling and identification of households for observations was done randomly using LC 1 household registers for the selected clusters. Systematic random sampling was used to select households that participated in the study which was done by choosing every 4th household on the list of those with children under five years. Although 15 households were selected for interview, only 10 were observed. The remaining 5 households were used for substitution in case of drop out or refusal. Selected households were visited a day before to introduce the study without disclosing that they are observing handwashing behaviour, but family life and sought consent of the household head and the primary caregiver (a biological mother or person directly responsible for the selected child) to participate in the study as well as select the index child (a child under five years to be observed) for the next day. Where the household had more than 1 child under five years, the index child was randomly selected using the odd and even days' method. Where the day of visit was odd then the younger child was selected and vice versa. On the following day the interviewers visited the households very early (5.55am) and spent 3 to 4 hours observing hand washing behaviour at key junctures.

3.2.2 Household structured interviews Structured household interviews were conducted in the same household where the observation took place. After the structured observation, the observer conducted a face to face interview with the primary caregiver of the index child. The objectives were to:

1. Identify intervening variables 2. Identify communication channels 3. Establish proxy for structured observations

3.2.3 Behavioural Trials (BT) Individuals were introduced to the behavior of HWWS and their experiences were assessed. This approach generated insights on how easy or difficult it is to adopt a new behavior and the perceived benefits and disadvantages. The objectives of the trial were to:

1. Find out the experience with soap during the week participants had it. 2. Understand the barriers to and drivers for handwashing with soap in homes particularly

focusing on: sensory (smell, taste, touch and visual); practical (environment); emotional (positive and negative feelings around handwashing).

The BTs were done in 5 districts where one sub-county from each was selected using PPS. At the sub-county level four (4) parishes were selected randomly with the help of the sub county chief and health assistant, from which the four mothers to participate in the behavioural trials, were selected. Placing the soap was for a period of 7 days where half of the participants received scented soap ( 225g pieces of Geisha soap) and the other half received unscented soap (A 600g bar of Key soap). The interviewers asked trial participants to use the soap and water to wash their own hands every day of the trial at key junctures including: after you’ve been to the toilet; after you’ve cleaned children up who’ve been to the toilet/changed your baby; before contact with food and before serving food. Interim visits to the participants (after 2-3 days) were made to check on the trial participants at least once or twice within the trial period (7 days) during which soap was re-supplied if necessary, asked


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participants what they have been doing and reminded them of the four handwashing moments of interest for the study. Post trial evaluation was done after the 7 days of the trial where trial participants were subjected to an in-depth interview with an aim of describing the experiences with soap during the week they have had the soap, understand the barriers to and drivers for handwashing with soap in homes particularly focusing on; Sensory (smell, taste, touch and visual), Practical (Environment) and Emotional (positive and negative feelings around handwashing).

3.2.4 Focus group discussions (FGDs) The FGDs five with women and two with men, focused on hand washing with soap at key junctures i.e. after contact with faeces and in handling food. The objectives of this approach were to:

Understand the emotional & social drivers & barriers around handwashing with soap. Establish the relative importance and collect stories around each of the selected

hygiene/hand washing motivators. Establish the existing/preferred channels of communication

Seven illustrations around motivators to HWWS including: disgust, purity, comfort, status, nurture, attraction and fitting in were used to understand emotional, social drivers and barriers to HWWS. Sampling procedures for the FGD was similar to that of BT.

3.2.5 In-depth interviews (IDIs) In-depth interviews were conducted with people who are influential in the community. A total of 12 in-depth interviews were conducted in 5 districts, 3 with health assistants, 2 with In Charge Health Centre, 1 with local council leader, 2 with community health workers, and 2 with Community Based Organizations officials, and 2 with religious leaders. The objectives were to explore perceptions and opinions on:

1. The emotional and social drivers and barriers around handwashing with soap. 2. Formal and informal communication channels used in the community.

Participants for the IDI were selected from the same sub-counties where FDGs and BT were conducted.


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4.0 Results This chapter concerns the results from the community study. Results are presented according to findings relating to the four key questions of the study: 4.1 what are HW practices, 4.1; who is HW 4.2; why HW 4.3 and how to communicate 4.4

4.1 Baseline data on handwashing behaviour (‘what’) Table 4.1: Hand washing with and without soap by primary child care giver Event

Total observed event

Missing data

Effective Total N

Any WH (%) Bathed body (%)

WHWS any soap (%)

After self-defecation

341 8 333 189 (57%) 9 48 (14%)

After cleaning child’s bottom

288 3 285 151 (52%) 3 54 (19%)

After other contact with stools

174 5 169 65 (38%) 1 18 (11%)

Before feeding or serving index child

347 4 343 139 (41%) 1 20 (6%)

Before handling food/drink (ready to eat)

303 6 297 100 (34%) 1 24 (8%)

Before eating

187 6 181 123 (68%) 0 15 (8%)

N=500 The table shows that of 500 caregivers observed, 341 went for defecation during the morning observation period. Of the 333 who could be observed, only 48 (14%) washed their hands with soap (i.e. 44% washed hands with water only) (Note that bodily bathing immediately following the observed event is already included within the used soap total, since hands must have been washed with soap during bating with soap). However, 57% altogether did wash one or both hands with water. 288 caregivers were observed cleaning up a child. Of the 285 who could be observed, 19% WHWS and 35% altogether used water (i.e. 16% washed with water only). Of 174 caregivers seen cleaning up stools or potties etc, 169 could be observed. Of these 11% WHWS and 24% used water. Of 347 seen serving or feeding the index child, 343 could be observed. 6% WHWS, and 35% altogether used water. Graph 1 show that HWWS is more frequent after contact with stools, especially after cleaning up child but overall handwashing with water is most frequent before eating. HWWS is rare in the sample. By comparison, when asked when they used soap yesterday 23% said they had done so after using the toilet, compared with 14% actually observed to do so. This suggests that asking the question may not be a good proxy for observation. Overall 224 events were observed where soap or another cleanser was used. In 93% of cases the cleanser was soap. Of theses Star and Key laundry bar soap were most common, followed by Bull and Geisha (toilet soap). 3 people used ash (1%) and 12 (5%) other cleansers (mostly Omo or Nomi detergent). No cases of local herbs or mud use were observed.


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Graph 1: Percentage HWWS and with water by event by primary caregivers

0

10

20

30

40

50

60

70

80

After defecation After cleaning child Before feeding Before handling food Before eating

perc

ent

HWWS HW Water

4.2 Target Audience (‘Who’) Women with children under 5 were selected as the primary target audience because their behaviour is most likely to have an impact on the several Millennium Development Goals having to do with childhood mortality. Table 4.2 summarises the characteristics of the caregivers from the household survey. Table 4.2: Characteristics of study participants Socio-demographic Characteristic % Household characteristics % Education None Primary Secondary Tertiary

20 54 18

Type of housing unit Detached Homestead Tenement Semi-detached

53 19 22 6

Age Range 18-75 Below 35 years

65

Ownership Owned Free private Free public Rented

75 5 2 18

Marital status Single Married Widowed/widower Cohabiting Divorced/separated

6 75 6 6

Type of roof Iron Grass

84 15

Number of children Under 5s 1 2 3 4 5

45 39 11 3 2

Energy used Cooking Firewood Charcoal Lighting Paraffin Electricity Firewood

72 26

85 11 2


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Aspirations of caregivers Focus Group Discussions included questions concerning the dreams and fears of women for their lives. A large number of the respondents aspired to give care to their children mainly focusing on education and basic necessities such as permanent shelter, clothing and feeding. The implication of this is that education and housing take a big portion of their income and education is seen as a basis for a better future mainly linked to gainful employment and social security in old age. Table 4.3: Dreams of Mothers Dream Dreams of Mothers (FGD Participants)

Education of children, Employment and Social Security

“I hope that my children go to school and become successful, get good jobs and take care of me”(FGD women, Mayuge District) “my dream is to have a job so that I can afford the basics of life like food, clothing, education for my children and build them a house…….now I imagine if my if my mother did not build the house we are staying in where would we be now” (FGD Female, Kiboga District) “You educate your children to help you when you are an old man….. You see I am ageing up so I have to educate my children so that they can help me when I am already old” (Male FGD, Bushenyi District) “my dream is to be well off, to be well off is like getting where we can earn a living so that we sustain our families and ourselves; this includes educating our children in good schools that are coming up” (Male FGD, Bushenyi District)

Desire for Better health

“I hope that my children are healthy and that they study successfully because I want to reach the apex of happiness when they complete their studies” (Female FGD, Mayuge District)

Faming Yields

“My dream is to dig, harvest well and educate my children so that when they succeed they take care of me in old age” (Female FGD, Mayuge District)

War “I dream that the war stops and people come back together and our children go back to school, know how to read and write and get better jobs” (Female FGD, Lira District).

Literacy Can read & write Cant read & write Can read

58 38 4

Main source of water Bore hole Well/spring Communal tap Piped water

38 38

12 11

Water availability Experienced water scarcity sometime in the year Yes no Number of times 1 2 3 4 6 12

31 69

33 18 17 7 5 10

Toilet facility Type Covered pit latrine-private Covered pit latrine-shared Uncovered pit latrine Covered VIP private Covered VIP shared Bush

46 26 21 2 2 3


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Table 4.4: Barriers and Biggest fears to Realisation of Dreams Barriers Description Health HIV/AIDS, cancer, diabetes, Malaria

Poor medical care/lack of drugs Insecurity War mainly in lira, political instability Economic Un employment, Politics-jobs are given to relatives, Poverty.

Lack of land to plant enough crops so that I can harvest enough to eat and sell to get money for

education Lack of capital to start up business

Seasonal changes-like us farmers you may buy land and plant crops but due to seasonal changes you

may lose out all your capital invested in agriculture. May borrow money from a bank or women group and fail to pay back hence remain in debt all my life.

Political Corruption

Biggest fear Fear Description Health related

HIV/AIDS especially brought by men Death Pregnancy of daughter Loss/departure of husbands

Insecurity related

• The War • Break-up in family • Defilement

Economic • Poverty • Corruption

Most of the participants across the districts and gender mentioned HIV/AIDS as the biggest fear for the future of their families. Corruption, famine poverty, war and government grabbing land were also reported as major fears, particularly in Lira. It’s important to note that health concerns were largely around chronic illness rather than malaria, ARI or any hygiene related diseases such as diarrhoea. This suggests that hygiene is not an important worry in Uganda. Most of the barriers and fears relate to life-threatening diseases, economic hardship and the war particularly in Lira district.

4.3 Barriers and motivators to handwashing with soap (‘Why?’) In this section we explore the reasons for handwashing and hindrances to handwashing. The section has been sub-divided into four sub-sections. Sub-section 4.3.1 is about the hypothesised motivating factors, using data from the five Focus Group Discussions (FGD) with mothers in Kampala, Bushenyi, Lira, Mayuge and Kiboga; sub-section 4.3.2 concerns the barriers to HWWS, where the data comes from the Behaviour Trials (BT) and the FGDs. Sub-section 4.3.3 concerns the factors that facilitate HWWS using data from the BTs. Sub-section 4.3.4 presents a crude quantitative analysis of the differences between hand washers and non-hand washers using data from the household survey crossed with the results of the structured observation.

4.3.1 Motivating factors From previous work we hypothesised 7 potential motivating factors: disgust, purity, comfort, status, attraction, nurture and conformity. Two further motivators, safety and habit, also emerged from the data. The data presented here is extracted from transcripts of FGDs which were prompted by the use of illustrated drawings of the key factors. The drawings can be found in annex 1. Additional material comes from the BTs. The definition of each factor as used by the facilitators is shown in table 4.5.


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Table 4.5: Motivating factors

Factor Description 1. DISGUST Dirt, contamination, smells – the things people find revolting, horrible, unappealing,

etc. 2. PURITY Cleanliness, spiritual purity, feeling untarnished. 3. COMFORT How you feel and how your hands feel when they’re clean. 4. STATUS Moving up in the world, being admired and respected. 5. ATTRACTION Attracting future partners, being attractive to your current partner. Looking good 6. NURTURE Doing the best for my children, putting them first - rewarding them, teaching them,

helping them develop. 7. FITTING IN Being part of the community, being seen to fit in, belonging, doing what others do. 8. SAFETY Avoiding disease in self and family 9. HABIT The tendency to keep doing a behaviour in response to a cue

4.3.1.1. Disgust Table 4.6 collates remarks made relating to disgust and how this might relate to handwashing. People related strongly to the idea that there might be disgusting contaminants on hands especially after the toilet. Often the idea of disgust was closely associated with the idea that there might be germs on hands if they were not washed, especially with soap.

Table 4.6: FGD quotes about disgust and HW Disgust

A clean person gets disgusted after latrine use; that is why they have to wash their hands with soap. I do not feel clean if I have not washed my hands with soap after leaving the latrine. I used to just eat before washing my hands thinking that it is only what comes out of my body that is dirty and not what goes in, not until I suffered from Typhoid. She used her hands [for the toilet] and she felt disgusted. People smear faeces on the wall, iron sheets and on the door. I have to wash hands, because after using a toilet, the hands are dirty and contaminated. I think toilets are the dirtiest places. What ever you find in a toilet is disgusting. Yes, we wash our hands after toilet because we feel the germs on our hands and hence disgust. For me disgust comes with imaging germs that flies may have spread to my hands while in the toilet I feel germs all over my hands after toilet so I have to wash hands. After toilet use, I imagine my hands dirty as the toilet itself so I have to wash them. It helped me remove germs especially from toilet (Mayuge BT) I rarely washed my hands with soap after cleaning my babies bottom (Mayuge BT).

People feel disgusted after going to the toilets because they are often in a dirty state. This is particularly true for the community toilets, where there are no cleansing materials available, so it is difficult to avoid hands becoming contaminated with faeces.

4.3.1.2. Purity Respondents discussed whether purity was an important factor in handwashing. The fact that Muslims practice ritual handwashing was often mentioned. Some people felt that purity was only appropriate to wealthier segment of society. There is an overlap between purity and comfort in that feeling ‘fresh’ or clean inside (also with disgust in the sense that cleanliness is the opposite of disgust). Here we are particularly interested in the spiritual or cultural component of this domain.


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Table 4.7: FGD quotes about Purity and HW Purity

I do not feel pure in my heart when I have not washed my hands. Us Muslims who have been taught from childhood that one must first wash (kutawaaza) with water in the kettle or jerrican that is within the latrine and use soap after leaving the latrine (several) I do not think I can be clean on the inside and be unclean on the outside and vice versa. There is nothing good like having something good in your mind. Just having a feel that you are clean inside will inspire you to always wash your hands. People who have a lot of money tend to have a lot of time to imagine inner purity since they have fewer problems.

4.3.1.3. Comfort Respondents often remarked that having sticky, oily or smelly hands meant that they had to WHWS, often related to eating. Having handled fish or cow dung, or having contact with animals was a particularly strong reason to use soap. They felt they needed to WHWS not just because dirty hands are uncomfortable, but also because any sticky materials/dirt/smell could be transferred from hands to other surfaces or people. Comfort or feel of hands is related to eating; dirty fingernails are seen as discomforting.

Table 4.8: FGD quotes about Comfort and HW Comfort Makes me feel fresh and good and that softness my hands.

After eating food you can’t move with dirty hands. I have got to wash my hands with soap after eating fish or any other oily foods. “My hands still feel they have food on them. I am a farmer so when I touch cow dung I WH …the hands are the basis of everything in life. I would feel very comfortable if my hands have been washed with soap. I can handle anything thereafter if my hands are clean. Hands feel good and soft… You can’t touch a clean thing when your hands are dirty. When you are from the toilet and you don’t wash your hands with soap you just feel uncomfortable. My children have now learnt that its important to HWWS even before eating (Kiboga BT)

4.3.1.4. Status There was a lot of discussion about whether the desire to gain status in the community was important in HWWS. Some thought cleanliness was extremely important to be respected, to be admired, to avoid being shunned, to meet important people and visitors (such as the Steadman team). One woman was even thought to have gained a political post partly because of her well-known clean habits. However others felt that people who were clean might be seen as giving themselves airs, getting too self important, and would hence not be respected. There is an issue here of whether a private act like HWWS might not be seen by others and hence might not work as a status label. Some confusion arose about sexual attractiveness and admiration for status. Status is associated with political power, economic status, education and type of job. Those seen to be too intent on keeping clean can become the target of gossip or ridiculed, so being ‘too clean’ is problematic.


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Table 4.9: FGD quotes about Status and HW Status Positive

[I WH] …so I am seen as a wise person. A clean person is easily accepted by others even when you touch someone. I have to be an example to others and also keep my home clean. If a person greets you at that moment, He/ She can feel the cleanliness of your hands. Soap is expensive to buy so as to earn respect in the society But a family that never gets Cholera will always be respected because they know that family is clean. It’s mostly women, they will start talking about you, that lady is dirty but after that, you will do it for respect. A person who is clean is always admired When I have gone to visit and they’ve brought soap and water for me to use. That’s when I wash my hands with soap so as to gain respect as a visitor. I think washing hands should be a practice in the community, whoever does it; he or she should be respected When a visitor comes, you gain a lot of respect for he will say when you go to Grace she, she is very clean, it does happen. Don’t you see us smart for a meeting today (all laugh) we washed because we knew we were coming to meet important people today. …when people identify me as a clean person, then I am easily befriended, I earn my self popularity …if they don’t wash their hands, their friends would shun them. Our community health assistant is a clean lady who happens to be everyone’s envy in the village and has hand-washing facilities in her home. She was recently elected to the LC II Council office and I believe it was because of her status in the community It helps boost self-confidence. It might even earn one a leadership position. My children are always clean and admired by other people because soap keeps us clean (Mayuge BT) I am very proud to be a clean person, my neighbours also admire me (Kiboga BT) My children are always clean and people admire me, they are always telling me these days we are so clean.(Kiboga BT) It makes the body smart (Bushenyi BT) Negative These are people who stay in towns and trading centres like Rwentuha. They always clean themselves, sit and wait for people passing by to admire and respect them. I think those are women who have house girls. They leave their house girls to do all the work, clean themselves in order for them to be respected by the neighbours and friends.

4.3.1.5. Attraction The issue of whether HW had anything to do with being attractive to one’s husband or others was contested. Many respondents thought smelling and looking clean would be an act of love and a way of encouraging a husband to be faithful. Others thought husband would be unlikely to notice if hands were clean, or even that women with clean hands might be suspected of having designs on men, being a prostitute or practicing witchcraft. Discussions in FGDs on this topic were often quite comical and animated.


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Table 4.10: FGD quotes about attraction and HW Attraction Positive

One has to be clean all the time so that your husband gets you fresh. When I am at home and I know my husband is coming back at a particular hour I will clean up the home and make sure the food is well prepared. I have to also clean my body. …when you have a husband you have got to show him a lot of love. So I have to keep my hands clean so that I do not put any dirt on him. Welcoming your men when you’re clean is good Those who steal people’s husband are the ones who wash hands to welcome men. Most men like clean women When your hands are clean, he feels it when he greets, he feels the softness of the hands. Because I believe a home which is clean earns the wife adoration from the husband Yes, cleanliness earns love Negative I don’t think it is true, it is only young girls who want men to admire them, l don’t think I need to be admired. Many times, someone you are supposed to be attractive to is also very dirty. …even if you keep your self very clean, they still get other women and marry them leaving you lonely. When the time has come for a man to get other women, even if you keep clean, it’s in vain. Here when you wash hands before receiving you husband with these village men they would think you are practicing prostitution and they say your men are teaching you how to do that. Some people think when you wash they would think you are practicing witchcraft so probably the witch doctor told you to do that to charm him. If you try to look clean you are trying to attract other people’s husbands. …what makes a man attracted to a woman is not hand washing with soap. I don’t think it is true, it is only young girls who want men to admire them, l don’t think I need to be admired.

4.3.1.6. Nurture Women regarded the love for their child and caring for them as a very high priority activity in their lives; most of their hopes and dreams were about educating their children so they would be healthy and successful. Most people felt that nurture was very important and that HW was an important part of child care. However, a few felt that they should look after their children even if they were dirty, so it was less important to WHWS before contacting the child. Mothers were equivocal about nurture as a reason to WHWS for child care. The picture-stimulus was taken rather literally by some mothers, who suggested that when a child needs care one couldn’t go and wash hands before touching them. Women don’t wash hands just to carry a baby; people love their children, but don’t show it by washing their hands before they touch their children. Also, children constantly need cleaning, so HWWS cannot be done all the time. Children were also considered to be pure and innocent (‘baby is an angel’), and therefore would not contaminate others (even their faeces). Table 4.11: FGD quotes about nurture and HW Nurture Positive

I have to keep myself and my family clean. I have to take the responsibility You as a mother should be clean and the child should be kept clean. When I am with my child I have to clean her up. I have to feed her on time, bath her on time. I love my children so much and they give me respect. A home without a child cannot be called a home It’s our responsibility as mothers to ensure there hygiene with in our homes to prevent disease. I ought to WHWS to prevent my children from falling sick Negative No because most of the time we are busy we find ourselves carrying them when we are dirty. (several) But for us you come back from the garden when you are very dirty and a kid just falls on you like that. Do you have time to wash your hands?


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4.3.1.7. Fitting in (Conformity) Although it is common that people are highly concerned with what others in their social groups do, this concept was not very well understood by participants, from the pictures. People know that other people in their communities are not habitual WHWS, so there was concern that people who do it would be marked out and hated because they were different. There is a strong motivation to conform with others, especially in the rural communities where people are dependant on the help of others in the community. Conformity may in fact be a reason why hands are not washed with soap in this sample. Table 4.12: FGD quotes about conformity and HW Conformity Positive

Washing hands to fit in is very common with us here I have grown up in a home where people wash their hands with soap so I would not do anything like preparing food without washing my hands with soap first. Negative Most women don’t wash their hands But you see the problem here is when you are clean people say you want to be different from them and they hate you If you try to be clean they say you are trying to look different from others in the community

4.3.1.8. Safety Safety was commonly cited by participants as one of the motivators to hand washing with soap mainly to kill germs, or reduce contamination which could cause diseases such as; cholera, diarrhoea as well as skin problems such as rush, scabies, ring worms and wounds. However safety was mainly linked to life threatening diseases such as cholera and dysentery because communities mainly receive health education about sanitation and hygiene when there is a cholera outbreak, so people associate HW with disease outbreaks. Despite this fact, the participants did not associate HWWS with outbreaks, suggesting that soap use has not been emphasised enough during the health education campaigns. However, outbreaks are seen as special risks, so when the outbreak is gone, the practice also stops. This is an indication that communicating around an epidemic outbreak does not induce a permanent habit. Table 4.13: Quotes about safety and HW Safety After washing my hands feel comfortable because soap takes away all germs (Mayuge BT)

Removes dirt (Mayuge BT) After HWWS before eating food I was very contented that what I was eating was not contaminated with germs (Kiboga BT) Some of my children had rash and now it is reducing (Lira BT) The soap was good when I used it my self I felt clean and knew I would avoid some diseases (Lira BT) It can not change the colour of skin (Bushenyi BT) If I did not wash my hands I would get cholera and diarrhoea for the children, many people do it because of Cholera (FGD) HWWS can prevent diseases, for example cholera (many mentions) Faeces bring cholera and dysentery (FGD)

Diarrhoea is not seen as a big threat and is usually associated with children growing teeth or weaning but not with handwashing, which limits ability to link diarrhoea risk with HWWS. Mothers suggested that other people who don’t HWWS don’t die, so the connection between handwashing with health is weak.

4.3.1.9. Habit Habit emerged from the data as a further category of motivator. It is a different sort of motivator – an ‘automated’ response to use of cues such as preparations to sit down to table to eat. Hence illustrations are juncture specific. People feel uncomfortable if they don not wash hands before eating. When people had the habit, it was mostly handwashing with water only before eating – and not after the toilet. This may therefore offer a foundation on which to build.


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It was mostly a habit not to handwash before any of the important junctures. Habits are hard to change. For instance some of the BT participants revealed that they were not handwashing at all or at some of the key junctures. The BTs suggested that a lot of the participants eventually got the HWWS habit at the key junctures and they said they were going to continue after the end of the trial. Table 4.14: Quotes about habit Habit It was a learning experience for my family because before we never used to use soap for washing

before eating but now its my responsibility, I never thought of handwashing before (Kiboga BT) After the toilet it was not important for me and my family to use soap but now we do, even after cleaning my child’s poopo I was hands with soap because generally in most cases we had very little soap before (Kiboga BT) Before I was lazy about HWWS after toilet use, before preparing and serving food and after cleaning the child, I would just do it once in a while but now I feel its my obligation (Kiboga BT) Washing hands with soap after toilet reason being that at first I used not to do it because I was using soap for washing and bathing only (Lira BT) Now we wash hands after cleaning the baby, I used not to do that before (Bushenyi BT)

4.3.1.10. Overall motivational concept ranking Finally table 4.15 presents an individual ranking of the motivational concepts by participants. Disgust and purity came out top closely followed by nurture then comfort and status. Attraction and doing what everyone else does were ranked lowest. We cannot however, set too much store by the rankings as the pictures were explained differently in each FGD, and the rankings were made after a lot of discussion, so they were often influenced by what had just been discussed. The pictures were meant to be taken as an illustration of an idea, but often they were taken very literally by the FGD participants. The idea that one might wash hands because of following what others do (7) did not make sense to participants as it was not what everyone did. Nevertheless it figured as an important factor, both as barrier and a driver, in the FGD transcripts. Strangely, the idea of purity didn’t seem to have been well understood in the discussion; however it was ranked very high. It may be that it was mixed with the idea of comfort. It would be worth exploring this further. People don’t talk about attraction easily in a social context, so it did not come up high in the group rankings from FGDs, although it was often ranked as a contributory motivator by individual cases. Table 4.15: Individual rankings of HW motivations by female FGD participants Motivator 1 2 3 T Rank 1. Disgust 18 6 2 26 #1 2. Purity 14 7 5 26 #1 3. Comfort 3 8 9 20 #3 4. Status 5 9 6 20 #3 5. Attraction 1 3 7 11 4 6. Nurture 3 12 10 25 2 7. Conformity 1 1 5 7 5 Table 4.16 below shows what people said when asked what the key times you ought to wash your hands with soap are. It can be seen that 84% of the total sample believe that soap must be used to wash hands after the toilet. It may be very effective to let mothers know that in their society people feel that HWWS is the right thing to do. Hence they may gain social approval by doing what others think is right (This injunctive norms approach has had a lot of success in changing risky behaviour in other settings)


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Table 4.16: Injunctive norms when are the key times you must wash hands with soap Event Total mentions Percent of total N=500 After toilet 418 84 After coming from Garden 297 59 After contact with oily/smelly things 258 52 Before feeding baby 119 24 Before breast feeding 82 16 After cleaning up a child 74 15 After touching animals 36 7 Before preparing food 19 4 After waking up 12 3 After cleaning house/compound 5 1 After touching dirty things like faeces/paraffin 6 1 When bathing 2 0 4.3.11 Socio-economic and motivational determinants of HWWS There are also a variety of environmental and psychosocial determinants of being a handwasher with soap at any critical juncture. In terms of environmental correlates of HWWS, people who HWWS are more likely to live in urban areas, have larger houses with non-earth floors, to have electricity, taps in their house or yard, a working TV set, radio and mobile phone. All of these measures are of course related to wealth, education, and other socio-economic characteristics. Several psychosocial determinants proved to be significantly different between soap-users and non-users. The biggest difference was that soap users expressed the opinion that they would be respected by visitors if they found a handwashing stand in their home. They felt compelled by disgust to wash their hands after going to toilet. Soap users are also more likely to say that soap-using is not a habit in their neighbourhood, and that those who don’t HWWS are irresponsible people. These results tend to suggest that people who wash their hands with soap take a moral stance about their community, and care more about their neighbour’s opinions. They also tend to find scented soap more attractive, which may simply be because they have more experience with these more expensive soaps. On the other hand, non-users of soap were significantly more worried about the price of soap, and more likely to agree that hands don’t become disgusting after cleaning a child’s bottom. These results present a fascinating picture of the world and minds of people who HWWS. Table 4.17: Environmental determinants of primary care giver being a soap user for HW Determinant Level Soap user yes n=127 Not Soap user n=482

Urban (Kampala) 20(29%) 48 Location Rural (Others) 107(19%) 434 1-2 rooms 79(19%) 335 House size 3+ rooms 48(25%) 147 Earth 63(17%) 317 Floor other 64(27%) 165 yes 20(27%) 54 Electric light No 107(20%) 428 Tap in house or yard 18(25%) 53 Drinking water other 109(41%) 157 yes 17(29%) 41 Working TV No 110(20%) 441 yes 109(24%) 349 Radio No 18(12%) 133 yes 49(26%) 135 Mobile phone No 78(18%) 347 yes 64(22%) 229 Own toilet or latrine No 63(20%) 253


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Table 4.18: Psychosocial determinants of being a soap user

4.3.1.12 Motivations-overall The results from the quantitative survey are consistent with the results from the FGDs about the importance of disgust as a motivator of HWWS. The existence of a Social Economic Status(SES) difference between soap users and non-users, the need to make the poor perceive soap as being worth buying for handwashing, promoting a sense of concern for social reputations and community responsibility might be associated with the need to feel clean through soap use. Overall disgust and comfort/purity emerge as probably the best motivators. Conformity or the need to do what others are perceived to be doing or what others think is important is likely to be a very important factor as well, though people underestimate its power.

4.3.2 Barriers A wide variety of barriers to the practice of handwashing with soap were uncovered by the behavioral trial interviews and in-depth interviews of key informants. In the following table, they have been organized into basic categories representing different kinds of barriers which would require different kinds of interventions to remove. First are physical barriers, which require the provision of new environmental resources to alleviate; biological barriers are associated with the body, and would require changes to people’s pattern of activity or in the interaction of soap with

Determinant Level Soap user Non-soap user Agree 19(21%) 70 Spoils food taste Disagree 106(21%) 390 Agree 27(18%) 121 Takes too long Disagree 99(22%) 354 Agree 46(23%) 151 Can tell if germs by looking Disagree 77(20%) 311 Agree 38(21%) 142 People in my village WHWS Disagree 49(19%) 215 Agree 54(26%) 254 No connection with missing

school Disagree 64(29%) 159 Agree 112(21%) 410 Compelled by disgust Disagree 10(15%) 57 Agree 21(21%) 81 Kids waste water Disagree 105(21%) 385 Agree 29(15%) 161 Soap too costly Disagree 93(23%) 305 Agree 97(21%) 358 Ashamed if someone saw Disagree 28(20%) 111 Agree 70(24%) 225 Scented is attractive Disagree 45(20%) 178 Agree 31(17%) 148 If someone watching Disagree 91(22%) 317 Agree 102(24%) 316 Not WHWS are irresponsible Disagree 22(14%) 132 Agree 119(21%) 443 Important to teach kids Disagree 5(22%) 18 Agree 122(22%) 430 Unseen contamination Disagree 2(10%) 19 Agree 73(23%) 247 Not a habit round here Disagree 24(16%) 122 Agree 115(22%) 415 I have been told important Disagree 10(18%) 45 Agree 29(17%) 137 Hands not disgusting child poo Disagree 94(22%) 325 Agree 105(22%) 375 HW is what good people do Disagree 17(18%) 79 Agree 123(22%) 446 Important after toilet Disagree 1(6%) 16 Agree 118(23%) 406 Visitors will respect me Disagree 3(7%) 40 Agree 17(20%) 70 I’ve never been told Disagree 107(21%) 397


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the body; cognitive barriers, on the other hand, require changes to what people know or believe; and lastly, socio-economic-political barriers require changes in social organization or social relationships. The table includes a number of quotes describing the rationale for a particular barrier. Table 4.19: Barriers to hand washing with soap PHYSICAL BARRIERS Convenience People can forget to hand wash, especially if the soap is kept far from the latrine Soap safety I was very conscious about where I was to keep the soap so that the hens would not peck it ( BT participant Kiboga District) Sometimes goats and cows eat the soap (participants unscented Bushenyi district) Time People have busy schedules and may not have time to HWWS (Community health workers Mayuge District) Some times we don’t because we are busy (BT Participant Kiboga district). At times you are from the garden and when you reach home with all the hunger, you just eat with dirty hands (FGD Mayuge District). But for us you come back from the garden when you are very dirty and a kid just falls on you like that. Do you have time to wash your hands? ( FGD Bushenyi District) You know now it is a digging and weeding season so, you are sure of touching so many things so you don’t wash your hands each and every time (BT participant Mayuge District).

Water availability Lack of water ( Lira District ) Lack of water and its cost (Local council Kampala district) Lack of water ( CHW Kampala) Lack of HW facilities and are not properly placed ( Health Unit, In charge Mayuge District) Fetching water takes a long time Well-designed water containers are hard to get; they are expensive ( Health Assistant Bushenyi District) Refilling water containers is tiresome ( Health Assistant Bushenyi District) BIOLOGICAL BARRIERS Fatigue People are lazy to do hand washing demonstrations are normally carried out but after sometime the containers are taken away (Health assistant Bushenyi District). I didn’t wash hands before preparing food because I was feeling lazy but felt convicted as if someone was watching me ( BT participant Kiboga District) People are tired from work ( Bushenyi Health worker) It’s tiring to wash hands every time you visit the toilet ( BT participant Kiboga) Sensory Before eating I don’t HWWS, because I could not use Geisha (scented soap) as it may make the food smell (BT participant Scented Soap Lira). The smell of soap makes me loose appetite for food (BT Participant Scented soap, Bushenyi District). The smell is not so good when you wash before food because it has a very strong smell (BT participant Unscented Soap Kiboga District). I could not use it for washing plates because of the smell (BT participant Scented Soap Mayuge District) I case you washed hands before serving food the smell would remain via food (BT Participant Unscented Soap Kampala District). PSYCHOLOGICAL BARRIERS Lack of knowledge People don’t know the advantages of HWWS (Religious leader Kiboga district) Low level of literacy ( Health Worker Bushenyi District) People not taught proper hygiene techniques (Religious leader lira district) I have never got someone to advise me about the importance of HWWS (BT Participant scented soap, Kampala District) People don’t want to be trained or aren’t interested Uneducated people do not go to meetings [where can learn of HWWS] People don’t wash hands because they are ignorant (CBO Rep, Bushenyi District) Health assistant not giving enough education on sanitation matters (Religious Leaders Lira district) People are not knowledgeable and are illiterate (CBO Kiboga District) People don’t put into practice what they are taught….demonstrations are done but people do not change ( Health Assistant Bushenyi District) Forgetfulness The exercise put me on tension, I had to remember all the time to HWWS (Mayuge BT) I forgot to wash before preparing food I just felt lazy about washing my hands. I felt convicted it was like


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some one was watching me ( BT participant Kiboga district) Uncertainty [Relative risk of diarrhoea to mortality/morbidity] Hygiene is not a top priority [when HIV is high risk and public sanitation is poor, hand hygiene is not most important thing to improve/worry about] (Religious Leader Kiboga District) My sister said she is tired of those people who keep telling her to avoid disease by washing hands with soap all the time as if those who wash hands with soap don’t die. After all our great grand parents did not have soap but they would live longer than we do today (Participant scented soap, Mayuge District) Fear of unknown People fear change, like to do what they are used to ( CBO Kiboga District) I was almost beaten by my husband because he could not believe that you had given me free scented soap, good enough you came back on time and explained ( BT participant Mayuge district) Beliefs/culture Not really, they don’t normally practice handwashing, because they have been living like that, not washing their hands (Health Unit In-charge Bushenyi District) According to the Ganda culture one is not supposed to wash their hands before touching a child ( FGD Women Kampala District) A woman might be doing some work and she sees a kid who is about to fall in to a trench she will just run to help the child out ( women FGD Kampala District) You don’t have to [WH before child] like you’re from burial ( Women FGD Kiboga District) Washing has to be practiced after a burial to wash away the connection with the departed person. This is very important in Baganda culture (Additional field findings Mpigi District District). In the Busoga tradition, they say you should not wash hands before holding the child. In that even a dirty person asks to carry a new born they cannot be denied since it is a belief that they are a blessing to the child (Additional field findings Mpigi District). I don’t HWWS whenever I urinate in the bathroom because urine does not contain any germs like faeces ( BT participant Kiboga District) I didn’t HWWS after urinating in the bathroom because I do not take urine to be harmful ( BT Participant Mayuge District)

(Lack of) habit People don’t have the habit to HWWS ( CBO Kiboga District) People who learn it when they are old are forgetful, unlike those who learn it when young ( FGD Mayuge District) I didn’t HWWS before feeding my child because I am just getting used to the practice of washing hands ( BT participant Kampala)

SOCIO-ECONOMIC BARRIERS Poverty Price of soap is high (Lira BT Participant Scented Soap) Soap is expensive ( Community Health Worker Mayuge district) Most of the time I cannot buy soap (Lira BT Participant Scented Soap) I also never used to allow my children use soap any how because they waste soap but this time I loosened up a bit (Participant scented soap, Mayuge District) It was mid week because the soap was getting finished and I had to minimize it (BT participant scented Soap Lira district) People are too poor to engage in activities that change their lives and cannot afford to dig latrines or soap (Health Assistant Lira District). Those who are rich wash their hands but the poor do not (Community Health Worker Kampala District) Those who can afford to buy soap wash hands than those who cannot (FGD Kiboga) ‘Civilized’ people (‘not for us’) Educated people always wash their hands (CBO Kiboga District) Civilized people HWWS; the uneducated nature of people keeps them from HWWS (FGD Kiboga District) She has even plaited her hair and worked on the nails those nails do not go to the garden (all laugh); for us we even use our nails to peel cassava if we can’t find the knife and children are hungry ( FGD Lira) If you want to be clean, people will say you want to be different and hate you (FGD Mayuge district) This can be associated with people don’t have millet gardens like us here in the village; those are people who do office work, have house girls (FGD Lira District).

Politics Politicians compromise the work of health workers ( Male FGD Bushenyi District) Community leaders are reluctant (Health assistant Kampala district)

Attitudes to health workers People chase away health workers (IDI) People despise health workers ( Health Assistants Bushenyi)


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This list of barriers constitutes a rich store of information about what people perceive to be the reasons for not washing their hands with soap. In some cases, barriers may be more perceived than real. For example, people complain about the lack of available water in IDIs as a barrier to handwashing. But in fact water is generally available (as shown in the household interviews); the complaints seem to be mostly about the lack of containers in which to put water for handwashing to make it easier to do. Barriers can interact to inhibit handwashing behaviour. For example, the belief that poor people are generally not used to handwashing (i.e., not ‘civilized’) is probably due to other barriers, such as lack of knowledge from their reduced ability to go to school, to buy soap due to poverty, and their greater exposure to other risks, such as HIV, cholera and other illnesses. Similarly, time to handwash and fatigue are both related to being busy. Being busy is in turn reflected in the fact that junctures occur too many times a day for some people to wash hands every time they arise. The sheer number of events may also cause people to forget sometimes to handwash (forgetfulness being another barrier). This problem of ‘forgetting’ can be alleviated by contextual reminders which work to cue the behavior.

4.3.3 Facilitators Debriefings after the behavioural trials brought up a number of factors which people felt helped them to engage in handwashing with soap after different kinds of junctures. The key facilitating factors were: availability of soap in plenty, availability of water, positioning of soap and the education provided on the key HW junctures. Participants were also reminded by their children to HW at certain key junctures. As these were relatively few in number, these reports are simply listed in Table 4.20 Table 4.20: Quotes on facilitators of memory for HWWS

My life is now different because I do not have to worry about where I should get soap from a friend or get it on credit from a shop (Kiboga BT)

Initially we used to forget but now it is very hard for both my children and I to forget ( Kampala BT)

After toilet, I remembered because you had emphasized it (Kiboga BT). After using toilet, the position where soap is placed made me remember (BT Mayuge) I never forgot to HWWS because the soap is placed so visibly nearby [the washstand].( Bushenyi

BT) After cleaning baby, children helped me remember.( Kiboga BT) After changing the baby, the smell of the baby’s urine helped me remember.(Bushenyi BT) After cleaning child, the water and soap were there nearby (Mayuge BT). When washing plates and cups (I used soap), because we ate fish and needed to remove the smell

(Lira BT). When washing clothes because you need to remove the dirt (Bushenyi BT)

4.3.4 Barriers and facilitators – Implications These reports confirm that distance to facilities is a barrier, and that the contrary, placing them close-by, is a facilitator of HWWS. The smell of urine is also a cue to the mother that she should wash her hands after cleaning up a baby; similarly, the smell of fish is considered objectionable, and leads people to wash hands with soap. The absence of these cues could also make women ‘forget’ to hand wash with soap. For example, a woman reported that ‘I forgot to HWWS [after cleaning the baby] because the urine was not smelly’, confirming the importance of smell as a facilitator for handwashing. In most cases, the way in which to remove the barrier can be determined in straight-forward fashion. In particular, barriers can simply be the opposite of motivators. For example, lack of a habit is a barrier to handwashing while having a habit motivates the behaviour to occur. Any


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activities that can get people to obtain the habit through trying out the practices – for example a challenge to try HWWS for 7 days would be worth exploring. Resistance to change (expressed in the in-depth interviews with the health workers, for whom it is a major professional frustration, and in debriefs of BTs where women expressed the sentiment that ‘people around here’ are resistant) might be overcome by a clever communication campaign. Generally speaking, it is probably easier for such a communication based campaign to change what people think, than to change the environment in which they live, which requires physical or economic resources to be provided at the local level, or to try to impact on policy, which depends on political influence. For that reason, communication campaigns tend to focus on removing psychological barriers rather than attempting to alleviate poverty or socio-economic differences between classes of people. A good communication campaign can, however, galvanise the support of politicians who find it worthwhile to be seen to be supporting HWWS. It is doubtful that communication programmes can influence the cultural beliefs that impact on the idea of HWWS. These beliefs are often connected to religious or traditional cultures for particular ethnic groups and so can be very deep-seated. If the handwash campaign can involve soap producers, then considerations of the sensory impact of soap can be considered as a focus of change. People commonly noted that the use of soap, especially scented soap, in the behavioural trials, had significant sensory effects on their hands and skin, making them smell good, feel softer, less cracked. Use of the soap to wash clothes also made the clothes and even the air in the house smell fresh (see Table 4.21). Bar soap is often bought piecemeal in 100kg blocks cut from a long bar. Soap companies might be prepared to make a new 50g mark on the bar so that smaller pieces could be cut specifically for handwashing. Table 4.21: Quotes on sensory benefits to soap

POSITIVE Smelt good most of the time when I used the soap (Lira BT) The soap makes me avoid unnecessary illnesses like diarrhoea, flies even avoid falling on you if the

hands are clean and the scent of the soap chases them away.(Lira BT) The soap was good, I washed blankets, clothes and all smelt fresh, I even washed the baby’s beds,

the soap produces form (Lira BT) The scent of this soap is good to smell on one’s skin (Mayuge BT) There is fresh air within the house because the clothes were clean and you can smell the soap scent

(Lira BT) It does not keep smelling in the hands after washing (Bushenyi BT) The soap has a good smell better than Lifebuoy which I usually use (Mayuge BT) “My hands felt smooth. It was really nice feeling that way after washing with soap”(participant

unscented Kiboga district) “Yes it made my hands smooth because I had some dirt under my nails”(Participant Perfumed Lira

district “They are soft after handwashing with soap”(participant unscented Kampala district) “My hands are now soft and I felt relaxed”(participant unscented Bushenyi district) “My hands were hard before handwashing with soap, they are now soft” (participant unscented

Bushenyi district 4) NEGATIVE

I could not use it for washing plates because of the smell (Mayuge BT) The smell is not so good when you wash before food because it has a very strong smell (Lira BT) Even when I don’t have Vaseline I can smear my self with that soap geisha (Kiboga BT) “It [smell of soap] makes me loose appetite for food” (Participant Scented soap, Bushenyi District).


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4.4 Communications for behaviour change (‘How’)

4.4.1. Media reach Secondary data gives a conflicting picture of the media consumption habits of Ugandans. For example, according to UDHS in 2001 shows that in Uganda, 48% of households have a radio, while only 4.5% have a TV set and the main source of information is word of mouth representing 49% (UDHS, 2001; UHPC, 2002). The Uganda all Media and Products Surveys (UAMPS) by Steadman, 2005 reveals that radio ownership is high at 95% with no marked differences by urban and rural as well as regions. With regard to TV ownership, overall ownership is low at 32% with the urban areas having the highest ownership at 69% compared to rural at 27%. However the UAMPS survey is skewed to the urban and peri-urban areas and did not cover the Northern region. The conflicting picture of the results from different surveys is also attributed to the fact that the surveys were conducted in different years. The Media industry in Uganda is also very dynamic and is growing very fast such that a small difference in years can cause a big change in ownership of radio. According to The Steadman Group UAMPS report(2005), Capital FM (44%) is the most listened to station overall. Highest listenership is in urban areas 63% particularly Kampala with 70% and eastern at 68%. There is high preference for stations that broadcast in local languages in central region (CBS 77% in central, Akaboozi 74% and Super FM 61%). In Kampala Akaboozi FM and Simba FM recorded the highest listenership with 67 % and 66% respectively. Our data is discussed below and it should be more up to date and be broadly representative of our target audience. Table 2.22 shows the channels of communication that were used by the community according to the FGDs. Table 4.22: Channels of Communication at community level

Channels of communication at community Within community

Outside community

Home care & Mgnt

Children care On health Style New songs

Person to person (friends & relatives)

Local councils

Radio Newspa

pers

informal Women

group Church

(mothers union)

Drama Formal Health

centre Local

council

Health centre Radio School

Health centres

Local councils

Person to person

Radio

Shops Friends meetings

radio video TV

Overall the most commonly used sources of information at community level were: radio mainly because it is easily accessed by many and cheap to buy; community meetings because these are attended by many people; community leaders because they are trusted and part of the community and workshops/seminars because many people are involved including those from out side the community. Quantitative data revealed that 73% of the respondents owned a working radio while only 9 % owned a working TV with Kampala recording the highest at 60%. District Variations showed that Kabale and Iganga had lowest ownership of the radio with 56% each.


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Graph 2: Ownership of TV and radio sets

Ownership of Radio and TV N=500

0%

20%

40%

60%

80%

100%

Total Kampala Mbale Lira Bushenyi Mayuge Kiboga Kabale Masindi Iganga Mpigi

Working radio Working television

Radio listening on a daily basis was high with 61%. Half the districts recorded listenership that was less than 50% and these include: Lira 28%, Kiboga 46%, Mbale 48%, Kabale 32% and Mpigi 36%. On the other hand majority of the respondents 74% do not watch TV. Viewership of TV on a daily basis was only 4% and the highest proportion was in Kampala with 24%. Leisure time activities and sources of information Out of the 500 respondents that were interviewed in this study, a high proportion of spend their leisure by listening to the radio (61%) and going to places of worship (64%). Local councils featured as the most prominent sources of information at 80% and included; home visits, village meetings and publicity through a micro phone and secretary for information. The radio recorded 55%, followed by word of mouth (through friends and neighbours) 49%. Exposure to promotions Exposure to promotions on health was highest for issues relating to HIV/AIDS and immunization with only 23% of the entire sample. Of these Bushenyi district recorded the highest level of exposure with 68% followed by Iganga and Kampala district with 32%. More detailed breakdowns of regional coverage with different media, radio and TV ownership, favourite programmes, favourite presenters, etc, have not been presented here, but are available for more detailed analysis when needed.


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SECTION THREE: The Schools Study

5.0 Introduction Primary school-age children are a different target audience from mothers and so were studied separately. Many habits are learned during childhood and children have different motivations and barriers for handwashing with soap from adults, since children of the age-group 5-13 spend much of their day in school, it was also decided to study children in school settings. School children are also the future of a country, and so an efficient target for changing behaviour. This section gives the approach and the results of the study of children in school.

5.1 Objectives Objectives of the school study were to Understand the risky hygiene practices of children Learn from a small trial of handwashing in school Investigate motivation for handwashing Determine how best to communicate handwashing messages to them.

5.2 Background on schools There are 14,000 primary schools in Uganda; 78% of these are governmental, the others are private; 79% of schools are rural. In Uganda, there are 5.4 million children aged 6-12; 83% of these totals are registered as in school. [UBOS, 2005] A study of sanitation and hygiene in 334 Ugandan schools nationwide conducted by Child Health and Development Centre in 2005 found that 59% of schools had VIP toilets; the rest had pit latrines. 71% of these latrines had dirty floors; one third had faeces smeared on their walls. Cleaning materials were lacking in 79%, with urinals not draining in 35% of school latrines. 14% had no doors, and 36% of toilets didn’t lock. 28% of schools lack gender-specific toilet blocks; 37% didn’t have separate blocks for teachers; 79% lacked toilets dedicated to particular classes. There were 70 children for each toilet on average (the national standard is 40:1). 14% of schools had handwashing facilities, and 10% had soap. Less than 20% had quantities of water provided up to standard; most water sources were further away than required by law. 40% had handwashing facilities, but only 60% of these were in use, and were more absent in rural areas and in government schools. 44% had no water in the facility: 80% had no soap or ash. 69% of children reported to wash their hands after use of a school toilet; only one-fifth of these report using soap. (CHDC, 2005) The Uganda Water and Sanitation Sector performance review (2006) indicated that the majority of the primary schools in the country have poor hygiene practices namely poor hand washing after latrine use and when it is done, it is with out soap. This review further indicates that 39% of the schools had handwashing facilities although only 60% of these appeared to be used.

6.0 Methods

6.1. Selection and description of schools for study Four primary public/government schools were selected randomly from within the districts investigated in the community study, one each from 4 districts (Bumasikye School in Mbale, Nyamirima School in Bushenyi, Otim Tom School in Lira and Nakivubo Blue School in Kampala district). The Kampala school was based in an urban slum while the other 3 were rural schools. Observations were conducted in 2 classes in each school (P3 and P6). All the four schools were government aided and were under the Universal Primary Education (UPE) scheme. All the schools had two governing bodies namely: the School Management Committee (SMC) and Parents Teachers Associations (PTA).


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The number of teachers in the four schools ranged between 11 and 24 including the head teachers. Enrolment in the four schools ranges from 326 in Bushenyi to 1, 356 in Lira district, with an average number of pupils per class ranging from 50 to 100. The ages for the pupils ranged from 5-15 years. Each school selected had a few handwashing facilities which were mainly small tanks with taps (6/8) while a few (2/8) were small jerricans, of 5 and 10 litres. Most of the handwashing facilities were situated outside the toilets (5/8), inside the toilet (2/8) and 1 facility were between classroom blocks. All the facilities had water at the time of observation. In each of the schools there was a teacher designated for sanitation and hygiene and some aspects of sanitation and hygiene are taught in science lessons and emphasized during school assemblies. In most cases, different classes were responsible on different days for keeping latrines clean and fetching water for handwashing. Soap was only available in one toilet: the girls’ toilet in the Bushenyi district school.

6.2. Overview of methods A variety of methods were used to achieve the objectives of the school study. Many of these are novel, being derived from a study of school hygiene practices in Senegal. [Sidibe, 2007] . Implementation of the school study involved two researchers, one male and one female, who spent 3 weeks in each school under study, implementing a wide range of methods to study children’s behaviours and the school context. These methods are summarized in Table 6.1. The idea behind the use of such multiple methods was to try to break through the barriers that are present when adult researchers try to find out about children. ..


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Table 6.2: School-based study methods

6.3 Behaviour trials Much of the activity within a school took the form of a behavioural trial that was aimed at exposing pupils to hand washing with soap within the school context. The preparation of the behavioural trial took place on the Friday of the first week with the two classrooms (upper and lower class) where the researchers were hosted. The rest of the school

Method Sample Description Data Participant observation

8 researchers Researchers were attached to one classroom for 3 weeks, observing the behaviour of children and adults, as well as documenting school facilities, materials and instruction practices

Field note diaries (N=8)

Structured observations

first 20 boys/20 girls observed on

one day per school

Researchers strategically observed the handwashing behaviour of children after toilet use during break-time on their first day in the schools

Observation sheets (N=8 x

20=160) Behaviour trials

2 classes per school (1 week scented soap, 1

week unscented)

Handwash stands, water and soap were provided to participating classes in the second week; children participated in a variety of special activities (designing messages), with a debrief per class in the third week

Debriefing notes, teacher

FDG transcripts (see below)

‘Hygiene detective’

4 children per school (2

boys/2girls from upper class)

Children were trained to take photos of risky risky behaviours by other children or adults related to handwashing or other hygiene practices, then given cameras for 2 days and later individually debriefed about their photos

Photos (N=96), Debriefing

notes (N=16)

Drawing one whole lower class

Children were asked to draw pictures of risky hygiene practices; then 10 individuals of each sex from each class were selected for debriefings to explain the pictures

Drawings, Debriefing

notes (N=80)

Money game

4 children per school (2


Each child was given photocopied 20,000 UG x note and were asked to write down on a form how they imagined they would spend it; then a group debriefing was held to talk about the different articles

Money form, Debriefing

notes (N=16)

Diary 4 children per school (2


Children given colourful pictorial format for recording the ‘story of my day’ (a complete day), with individual debriefing to provide insights into daily routines and interactions with family members, school friends and out of school children, potentially about feelings or events which may be too embarrassing or challenging to obtain through an interview

Diary forms, Debriefing

notes (N=16)

Individual debriefing of children

1 per school (whole upper

class)

Children asked to write down 1 like/1 dislike of handwashing with soap based on experience with BT

Like/dislike Forms,

Debriefing notes (N=198)

Drama ‘Debate’

1 per school (upper class)

Children identified to play roles of government officials (various ministers of health, education, finance, gender) and given the task to gather arguments from their peers in the school advocating for the advantages (drivers) for the introduction of the new behavior in the school or sceptical journalists that collected views on the challenges (barriers) of introducing the new behaviour, presented as arguments in a national press conference, conducted before the class and school administration, done at end of behavioural trial

Drama tapes and transcripts

(N=4)

Teacher focus group discussion

all teachers Discussion of likes/dislikes of the behavioural trial, suggestions for improving handwashing in future

FGD transcripts

(N=4) In-depth interviews

1 head-teacher (2 interviews at

beginning and end), teachers in

charge of sanitation

Experiences with behaviour change, experiences with intervention, suggestions for improving handwashing in future

Interview transcripts

(N=16)


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community was not informed of the changes that were being planned. Upon return on Monday, the school communities found changes in the school including: two handwashing facilities (1 for upper class and 1 for lower class) and soap provided next to the handwashing facilities. The hand washing stands developed to the height of the children were provided in front of the two classrooms in the four schools. Figure 2 An intensive ‘advertising’ campaign was carried out in all the schools during the first week of the behavior trial. Banners/posters were designed by the children with messages to promote handwashing with soap. At the end of the second week, an evaluation of the behavioural trial was carried out by: individual debriefing with children, drama focus group with pupils and debriefing with the adults in the schools. The table 6.2 summarises the methods.

After visiting the toilet this pupil washed hands without soap yet the facility had the soap


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7.0 Results

7.1. Baseline behaviours of children in school (‘What’) Over half of the observed pupils (87/160, or 54%) did not wash their hands after toilet and only 8/160 (5%) washed their hands with soap (only the toilet in the Bushenyi school had soap available). Table 7.1: Handwashing behaviours in school

Handwashing behaviour District Sex Handwashing

with water only Rinse one hand with water only

Rinse one hand with soap

Handwashing with soap and

water

Do not hand wash

Boys 14 0 0 0 6 Lira Girls 10 1 0 0 9

Boys 10 1 0 0 9 Bushenyi Girls 4 0 0 8 8 Boys 9 0 0 0 11 Kampala

Girls 8 1 0 0 11 Boys 0 0 0 0 20 Mbale

Girls 7 0 0 0 13 Total 160 62 3 0 8 87 From the structured observations of handwashing behaviour at households level (see the Community Study), a total of 203 school-age children were observed of whom 81% did not wash their hands after defecation while 19% washed their hands as shown in Table 7.2. Figure:3

The 11-year old P5 boy was leaving the toilet without washing hands Figure 4

Primary 3 female pupil washing hands without soap


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Table 7.2: Handwashing after defecation by School Aged children at Community and in Schools Handwashing Behaviour School N= 160 Home N= 203 No washing 54% 70% Handwashing with just water 41% 16% Handwashing with soap 5% (only one toilet) 14% Number of observations 160 203 The levels of handwashing after defecation at home is lower than at school which suggest that the school environment facilitates hygiene behaviour, possibly due to reminders at school in class, compulsion and peer influence. It is likely that handwashing with soap would also be higher at schools, should facilities and soap be made more widely available. Findings from drawings and photos by child detectives revealed that lack of handwashing before or after eating food or a snack, after visiting toilet were key risky behaviour in schools. Poor sanitation and hygiene conditions were also depicted in the drawings, including flies around the toilet, defecating or urinating outside toilet, use of dirty water, poor refuse disposal and dirty cooking environments. Interestingly, the drawings also included adults within the school not practicing handwashing with soap, mainly before eating food and snacks. Children wanted to photograph teachers not HWWS, but did not dare. This hypocrisy offended their sense of morality. Similarly, the photos indicate two main scenarios: no handwashing after toilet use or before eating food or a snack, and handwashing with water alone after toilet and before eating food or a snack such as cassava, sweet potatoes, maize, sugarcane and mangoes. Other pictures showed pupils drinking water with hands. The barriers depicted in the photos were lack of soap and times, as children were portrayed rushing to play especially during break time. Rain was also revealed as a barrier to toilet or handwashing facility use due to dirty trenches and water logging around the handwashing facilities. Table 7.3: Photos/Drawings of Hygiene Behaviours Handwashing Behaviour Photos N=80 Drawings N=80 No handwashing after toilet 23 26 No handwashing before eating snack 12 28 Handwashing with water after toilet 11 34 Eating food without handwashing completely 23 7 Defecating/urinating out side toilet 5 14 Handwashing with soap after toilet 1 17 Eating next to the toilet, in toilet or next to faeces -- 13 No handwashing before eating a snack 12 -- Handwashing with one hand after toilet 4 3 Handwashing with water before eating a snack 6 -- Handwashing with water to drink water 6 -- Handwashing with soap before eating food -- 3 Handwashing with water before eating food -- 2


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Figure: 5

A primary 6 boy is urinating on a tree where there is a “Keep the School Clean Poster”

Figure: 6

A girl is rinsing her mouth while others have come to wash their hands after using the latrine Figure: 7 A girl washing hands after using the toilet


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Figure: 8

7.2 The school environment for hygiene Interviews with head teachers revealed that the challenges to quality education included poor infrastructure and general management of schools, as well as poor motivation of teachers including poor pay, lack of promotion and heavy workload; this results in a general lack of creativity by teachers. Figure: 9 Hygiene practices such as cleanliness, handwashing before and after eating food, personal, class and school cleanliness were mainly reinforced by teachers and school prefects through lessons in school and health parades. The findings also indicated that one teacher is designated for sanitation and hygiene; some aspects of sanitation and hygiene are taught in science lessons and emphasized during school assemblies, construction of urinals for boys, provision of tippy-taps for teachers and pupils, putting up posters with information on hygiene, digging rubbish pits and putting in place rules and regulations were reported as key ways of emphasising hygiene in schools. However, it appeared that such activities, though present in theory, were not consistently implemented. Children were often disgusted and angry about the state of their schools and toilets and hygiene practices (photo debrief). Using this disgust to motivate handwashing or helping the children to take up the campaign as a moral issue might also be effective.

7.3. Children as people (‘Who’) A picture of how children live can be found in their accounts of how they spend an average day. Their diaries revealed that the day for most children starts between 6.00am and 7.00am and ends between 9.00pm and 10.00pm. In the morning, children wake up between 6.00am and 8.00am; greet their parents and pray; prepare for school including making their beds, brushing their teeth, bathing, dressing and some but not all, take breakfast. Many did some work before going to school,

This group of boys was washing hands without soap. The soap was not available at the facility

A Primary 2 girl (dressed in blue) came from the toilet and washed her hands with soap


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mainly fetching water, sweeping the house and compound and taking animals to grazing areas (e.g. boys herding goats). The other part of the morning involved going to school where they were involved in class work, discussing with friends, cleaning school compound and playing. In the afternoon, pupils tend to go back home for lunch (although some have it at school); going home for lunch was reported to be tiring. Once back in school, children engaged in class-room learning, cleaning of the school (including slashing, washing plates after lunch); playing games such as football, netball and dodge ball; and then going home, where they were involved in greeting their parents, reading books, washing plates, cooking for the girls, collecting goats from grazing areas for the boys, and collecting firewood and washing their clothes in particular their uniforms. A few of the pupils mentioned prayer before sleeping, taking evening tea and watching video, helping parents in their businesses such as attending to a bar and a shop. Selling in the shop was associated with missing playing with friends. The debrief of the diary users found that the evenings were the favourite part of the day by most of the pupils because they had less activity, were relaxed, had time to play, it’s the time they get back home, eat and sleep. It is evident in the children’s stories that their day is packed with activities with little time to rest and a lot of pressure in the morning before going to school. Boys and girls have chores every day of the week, but may be free to play after doing these chores on Saturday and after church on Sundays.

7.4. Why children might wash hands with soap (‘Why’) Motivations for children’s’ handwashing can be determined by examining the debriefing forms of children after behaviour trials, as well as drama enactments. What children reported as liking or disliking about the BTs is listed in Table 7.4 Table 7.4: Likes and Dislikes of Children on Practicing HWWS by District

Number of Responses By District Total Likes Bushenyi Mbale Lira Kampala

Soap kills germs 16 31 48 33 128 Prevents diseases 13 13 41 8 75 Removes dirt, leaves hand clean 5 9 8 10 22 Soap has good smell 9 3 1 5 18 Removes bad smell 10 2 1 3 16 Scented soap has a good smell 9 0 0 0 9 Promotes health /hygiene 2 1 3 2 8 Its important to HWWS after toilet 0 5 0 2 7 Soap makes my skin soft 0 1 4 0 5 Its important to HWWS before eating 0 0 0 2 2 Dislikes Soap is expensive so the habit will not last 3 24 26 03 56 Soap has a bad smell-unspecified 8 4 19 13 44 Some people are allergic to soap 3 9 9 1 22 HWWS wastes a lot of time 0 3 16 2 21 Soap remains in hands/nails 1 1 7 8 17 Bad smell of scented soap 8 4 1 0 13 Soap does not kill germs 4 6 1 1 12 Bad smell of unscented soap 6 4 1 1 12 Wastage of soap and water 2 2 3 5 12

These data indicate that children’s say they compliance with handwashing is motivated by the fact that soap is believed to kill germs, prevent diseases such as cholera, diarrhoea, chicken pox, and prevent skin problems such as ring worms and skin rash. Soap also makes hands clean or smell good, makes skin soft and removes dirt, or promotes health or personal hygiene. It also helps to avoid contamination of food with faecal matter. Provision of handwashing facilities and soap, constant availability of water and the active participation of children in the activities were key drivers to handwashing (see Table 7.5).


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Table: 7.5: Drivers to Handwashing in Schools during the BT

Drivers in school

“The pupils sensitized their fellow pupils” (Teacher Nakivubo Primary School, Kampala) “Handwashing with soap helps to remove bad smell from hands” (Debrief with child in

Nakivubo P.School Kampala) “When I wash my hands with soap after visiting toilets I will not get germs and diseases”

(Debrief with child in Nakivubo P.School Kampala) “Soap removes germs that can cause diseases like cholera and dysentery. When you get visit the

latrine, you get into contact with germs and bacteria”. (Drama FGD Children in Bushenyi) “Provision of handwashing cans and soap” (Teacher Bushenyi). “Teachers were role models” (Teacher Mbale) “Physical interaction and participation of children was important in the campaign” (Mbale

teacher) “Using soap like Geisha can control diseases like ringworms and smallpox” (Drama FGD Lira)

“Washing hands with soap is cheap in controlling diseases” (Drama FGD Lira ) “Every new thing like the cans were fascinating to the pupils, they were delighted about it and have been using it” (Head teacher Lira District) “When they wash hands regularly it can make a difference to them in areas of personal hygiene, academics and self esteem since they become comfortable with them selves and they will be socially acceptable, they will also be role models in their families since they live exemplary” (Head teacher Bumasikye P/S Mbale District)

From behavioural trial debriefings, it appears that children recognize a number of barriers to handwashing with soap, including the lack of handwashing facilities, soap being too expensive and therefore tends not to be available in schools, water being hard to get, a lack of time for everyone to wash hands during breaks, mud around handwashing facilities can get children dirty, and teachers don’t emphasize the importance of handwashing with soap (see Table 7.6). Table: 7.6: Barriers to HWWS- Lessons from BT in Schools

Barriers “One can was not enough for the big number of children. There was struggle especially during break and lunch time (Teacher Nakivubo Primary School) “Handwashing facilities were not enough and this caused overcrowding (Teacher Bushenyi District) “Washing facilities were not enough hence caused over-crowding (Teacher Bumasikye Mbale District) “The containers to fetch water to fill the containers were not enough sometimes children could use watering cans to fill the containers (Teacher Bushenyi) “Soap smells bad (Debrief with Child in Nakivubo P.School Kampala) “Soap smells bad when I am going to eat (Debrief with Child in Nakivubo P.School Kampala) “When I use soap to wash my hands the smell of soap remains in my hands and when I am eating I feel like vomiting (Debrief with Child in Nakivubo P.School Kampala) “Some children play with water and soap…..water floods in our compound (Debrief with Child in Nakivubo P.School Kampala) “Some people are allergic to soap like Mekako and Geisha which causes skin rash (Drama FGD Children in Bushenyi District) “Soap is expensive especially scented soap, I do not think this school can afford buying soap especially Geisha (1,000/-). (Drama FGD Bushenyi) “It is tiresome since the handwashing facilities are quickly emptied and need regular refilling (Teacher Bushenyi District) “During the dry season it is hard and tiresome to collect water (Teacher Bushenyi District) “Handwashing wastes a lot of time because if you are from the toilet and you have to go back to class, soap can delay you since you have to rinse your hands (Drama FGD with Children in Bushenyi District) “Handwashing with soap wastes soap and water (Debriefing with Children Bushenyi District) “Soap maintenance was a problem because some pupils took it (Teacher Otim Tom Lira District) “Only two classes were sampled which made other classes to rival for the few containers” (Teacher Otim Tom, Lira District)

A number of negative beliefs about soap emerged primarily from the debates but also BT debriefings: that the use of soap makes skin dry and pale, can cause disease (skin rash), and has a bad smell which can cause vomiting, sneezing and difficulty in breathing. More children thought soap smells bad than smells good. In school, not using soap can be basis of punishment, so children can fear the need to wash their hands. A few children felt soap does not kill germs, and is wasted in


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handwashing. They mentioned possible substitutes for soap including warm water, paraffin, ash, lemon and pawpaw leaves as a way of avoiding the use of soap. Teachers suggested that the BT, by giving children experience of handwashing with soap, made the advantages of such practice more obvious to children. They were surprised by how easily children took up the new behaviour. Some children were so enthusiastic; they took the message home as well. Table 7.7: Advantages of the new behaviours Advantages “I liked the handwashing campaign in our school because every child was washing hands after

visiting the latrine which in turn prevents them from getting diseases” (Teacher Bumasikye Primary School Mbale District) “Since it is one of the ways of preventing diseases, children learnt by doing it practically” (Teacher Bumasikye Primary School Mbale District) “Created awareness of preventing some of the diseases like cholera, dysentery which can be controlled by handwashing” (Teacher Otim Tom Primary School Lira District) “The exercise has made pupils to be co-facilitators both at school and at home” (Teacher Otim Tom Primary School Lira District) “It promoted the handwashing habit and personal hygiene”(Teacher Otim Tom Primary School Lira District) “The pupils have quickly adapted to handwashing after the use of latrines and some have introduced the system in their hands” (Teacher Nyamirima Primary School Bushenyi District)

7.5. How to get children to wash hands with soap? From the various instruments used to probe children’s lives, a number of conclusions can be reached concerning how the very low rates of handwashing with soap at school might be increased.

7.5.1. Communication with children In rural areas, children’s access to media is often limited to radio programmes. In urban areas, they have greater access to TV and hence images from around the world and other ways of life which excite their imagination in ways not characteristic of rural children. It appears that generally there is not a specialized culture surrounding children, at least in rural areas – they do not have specialised musical groups, literature, or games which can be used to identify subgroups. Instead, they adopt adult traits: football team alliances, adult music and listen to adult radio programmes (e.g., about adult romantic involvements). At best, boys use English football teams such as Chelsea and Arsenal to distinguish themselves into ‘fan’ groups. This condition places significant constraints on how to reach children on a national scale. Nevertheless, a variety of strategies might be used to communicate to children the need to wash their hands with soap at critical junctures. Considerable effort was put in to determining what children find to be ‘cool’ because this is a general way to motivate them to learn new behaviours. To explore the pupils’ understanding of the notion of ‘cool’, pupils were asked to list the things they would buy in 20,000/= shillings. The common items that were listed were mainly to do with school which included; shoes, school uniform, school bag, school jacket, school fees, books both exercise and text and pens. The unique items in the first category that were not related to school were goat and turkey. Other items outside the school that were listed were medical care, Christmas clothes, brick game, a tie and watch. The reasons for the selection of the items were that education is valued; parents could not afford some of the items because they are expensive and pupils wanted to be like those who have the items.


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Table 7.8: Showing the three most expensive items per pupil in the money game Items District Sex

First Amount Second Amount Third Amount Boy 1 School bag 10,000/= Books 8000/= School shoes 4600/= Boy 2 School uniform 12,000/= Shoes 5,000/= Dozen of books 2,000/= Girl 1 School bag 5,000/= Medical 5,000/= School shoes 5,000/=

Lira

Girl 2 School uniform 5,000/= X-mas dress 4,000/= Shoes 3,000/= Boy 1 Shoes 6,000/= Books 2,000/= Tie 2,000/= Boy 2 Goat 6,000/= Coat 3,000/= Shirt 2,000/= Girl 1 Shoes 8,000/= School uniform 4,000/= School bag 4,000/=

Bushenyi

Girl 2 School uniform 5,000/= Shoes 3,000/= Dress 3,000/= Boy 1 School uniform 8,000/= School bag 2,000/= Ex. Books 1,800/= Boy 2 Shoes 4,000/= Text Book 3,000/= T-shirt 2,000/= Girl 1 Snickers 5,000/= Brick game 3,000/= Watch 3,000/=

Kampala

Girl 2 Jacket 5,000/= Open Shoes 3,500/= Bag 3,000/= Boy 1 Shoes 6,000/= X-mas clothes 4,000/= Goat 4,000/= Boy 2 School bag 8,000/= Hen 4,000/= Books 2,500/= Girl 1 Turkey 10,000/= School dev. Fund 5,000/= School fees 5,000/=

Mbale

Girl 2 Goat 20,000/= From debriefings after the money game, it appears that rather than define cool by what they own or how they spend their money, children believe that being cool means being ‘smart’ and being ‘bright’ (clever or getting good grades). Being ‘smart’ means having complete uniform which is ironed, clean (no dirt), and of the right size. A child from a well-to-do family can afford to give their child a uniform, book, and pay school dues on time. Being ‘bright’ is valued because one can get a good job and support oneself in future. Table 7.9: Cool and Smart Cool ‘I use soap to be smart’

“I can define cool using an example of our head girl, she is very smart because she puts on ironed uniform, black covered shoes, grey stockings, black school bag and her parents are rich”(Female Pupil Bushenyi District). One who has acquired education and is knowledgeable enough, has studied and is quiet well off” (Male Pupil, Mbale District) One must have shoes, be smart, academically bright, have a bicycle and also be a good drama actor” (Male Pupil, Bushenyi District)

Since children value playing above many other activities apart from learning, making handwashing with soap a fun or playful activity might also work. It might also be possible to use role models in the communication campaign which children can relate to as examples of high-status individuals whose behaviours they would like to imitate. From the children’s diaries, it appears that children use the head girl, health prefects, musicians, UK footballers, and Ugandan marathoners like Inzikuru as role models or influencers. However the main influencers of children’s behaviours are probably authority figures close to home: teachers and parents. The central role of teachers as enforcers of hygiene rules was also emphasized. Most of the diary participants revealed a great desire for education. This presents opportunities for positioning the handwashing campaign in the school context. Teachers and head teachers believe that active participation of children in the design of handwashing promotion messages, regular debates and monitoring the handwashing trends are novel ideas that can help in making handwashing a habit in schools.


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7.4.2. Message positioning The handwashing campaign could use a variety of child centred strategies to make children want to WHWS. These could include making it fun, involving the children fully in any hygiene activities, making it the normal thing for children to do, for example by active monitoring by respected kids, such as class monitors. Since children already know about handwashing and germs, but generally do not practice HWWS, more learning about germs and diseases may not work. Children were often disgusted and angry about the state of their school and toilets and hygiene practices (photo debrief). Using this disgust to motivate handwashing or helping kids to take up the campaign as a moral activity might also be effective. However, the significant differences between genders and age-groups might require segmenting the target audience. Boys and girls have different motivations and interests, and older children have more sophisticated abilities to take in different kinds of information (see evidence in Table 7.10). Table 7.10: Gender and Age Gender and age

“Naturally boys are stubborn and they take interest in things quickly and lose interest, while girls take interest slowly and keep it” (Head Teacher, Lira District). “Girls can practice handwashing better than boys because boys are careless” (Head Teacher Bushenyi District) “Older children can do it better because they know the dangers” (Head Teacher Bushenyi District)

7.4.3. Institutional issues Promoting handwashing with soap in schools will depend heavily on the availability of soap and water, and the provision of adequate handwashing facilities. This is a major challenge, and one that soap companies may wish to get involved in, given that school kids can carry messages about their brands home. Sensitization and involvement of key stakeholders, including teachers, parents and community members is critical for the success of the campaign.


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SECTION FOUR: Conclusions

8.0 Conclusions Given the results presented in the previous section, a number of conclusions and recommendations can be drawn.

8.1 What we have learned About handwashing practice: Handwashing with soap at critical junctures is not a common practice in Uganda, either in the

general community, nor in schools, despite a relatively rich history of promotion activities around sanitation, water and hygiene.

Soap and water availability is generally good, and in some areas there are centrally located places for washing hands such as drying racks where soap is kept. Such places may convenient for HWWS.

Washing hands with water is seen as ‘good enough’ and is much more common than handwashing with soap.

People feel too busy to wash their hands with soap on every critical juncture, which are many during a day.

Handwashing is a low priority for the use of soap, below laundry, dishwashing and body washing.

95% of households have soap. Most people know about HWWS but fewer people practice it

About households: Soap is in the female domestic category of purchases. Traditionally, the man is supposed to

give their wife money each day for domestic uses, which the women prioritize, and may use little savings to buy soap. This tradition is slowly changing, so that now women make their own money which they can also spend on soap.

Men tend to think soap is expensive. Many women think it is important to keep their men happy because they are to some extent

dependent on them for finances and security in society. About community: Health workers, members of CBOs, NGOs and LCs are perceived by mothers as being

disdainful of the communities they serve. About motivations to hand wash with soap: Disgust at the possibility of contact between hands and sources of contamination (particularly

faeces) is strongly associated with handwashing. Handwashing removes the threat of bad smells, and unseen germs, and therefore leads to a feeling of comfort and possibly purity (depending on background).

Comfort is feeling fresh, smelling good, clean. Nurturing your child - keeping it safe, healthy, and educating it -- is important to women, but

possibly less directly linked to handwashing. Conformity to norms is a significant motivator in these communities, but since most people do

not hand wash, this means people currently conform to an undesirable norm. However 84% of mothers believe that washing hands with soap after defecation is a MUST. It

may be possible to generate higher HWWS rates by letting everyone know that this is the injunctive norm.

Some mothers see a logical connection as follows: Safety/health work/garden money education of child child gets good job child gets a lot of money take care of me when old. However, not all people believe in each link, and it may be too complex for a single issue campaign


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Handwashing can get in the way of nurturing your child. A loving mother should be spontaneous with her child, not run away from a needy child to wash her hands.

Habit is recognized to be a common way in which people learn to hand wash – learning early is thought to make the habit stick.

About barriers to/facilitators of to handwashing: People (including health professionals) feel that there are many more important health concerns

than handwashing Mothers do not perceive a clear, immediate link between handwashing and health or any other

benefit Even when they do, diarrhoea is not regarded as much of a threat Cholera is regarded as a threat, however the motivation for HWWS goes when the threat goes It takes a lot of time to hand wash at all critical junctures, which are many and frequent Hand wash facilities (soap, water) can be inconvenient to access However many people have dish rack stands centrally in their compounds where soap is kept.

This can make a good family HW centre. Soap is perceived to be expensive, however, a small piece, enough for a typical family to HW

for a two weeks, costs only 100 UG.SHS –the same as a cigarette Some cultural beliefs are inimical / contrary to handwashing with soap, for example that hands

should not be washed before contacting a child or that washing is associated with burial. These are very difficult-or impossible- to change

Handwashing with soap is perceived to be an activity of people ‘unlike us’ (i.e., rich, educated people)

About schools: Control over the ethos / culture of the school is in the hands of the School Management

Committee (SMC) and Parent Teacher Association (PTA), and implemented by the head teacher.

Facilities are poor and time and organisation is needed to get water for sustaining handwashing. There is little emphasis on handwashing in the hygiene curriculum. No one is responsible for toilets or handwashing facilities.

About children: There is tremendous emphasis in Uganda on the need for children to be educated to ‘get ahead’.

Families spend more money on educating their children than on anything else, including medical treatment.

Many children don’t like the smell of soap, and some believe that it is damaging-causing rashes and allergies

School-aged children spend a lot of time working or in school, with relatively little time or materials for play until late afternoon and evening, or on weekends.

Key influencers of children tend to be local: parents, teachers and peers. Other role models included famous athletes and musicians.

Because of the great emphasis on education by children themselves, they tend to see their teachers as their ‘gateways to the future’.

The most admired peers are the cleverest child, good leaders (the head boy/girl, prefects/monitors), children from rich families, well-mannered children, pretty girls.

School-age children behave differently at home and school with respect to handwashing. They do a lot less HW at home than at school.

Since children already know about handwashing and germs, but generally do not practice HWWS, more learning about germs and diseases may not work.

Children were often disgusted and angry about the state of their school and toilets and hygiene practices (photo debrief). Using this disgust to motivate handwashing or helping kids to take up the campaign as a moral issue might also be effective.

The handwashing campaign could use a variety of child centred strategies to make children want to WHWS. These could include making it fun, involving the children fully in any hygiene


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activities, making it the normal thing for children to do, for example by active monitoring by respected kids, such as class monitors.

8.2 Major challenges There is a view amongst mothers and some key influencers that HW is too trivial to be a public health concern given HIV/AIDS and malaria, from which people are seen to die. People do not die because they didn’t wash their hands. People also expressed concern over epidemic diseases such as cholera and typhoid rather than diarrhoea. Poor people expressed the sentiment that ‘handwashing is not for people like me’ – that is, it is practiced by ‘civilized’, educated, rich people. This extends to the feeling that those who emphasize being clean are seen as trying to be better than their fellows, and thus hated by their community. Among rich people, this sentiment is mirrored in the view that the poor are ‘lazy’ and ‘primitive’. Thus, there seems to be a recognition of significant differences between rich and poor in Uganda – even a ‘culture of poverty’ which keeps the poor in their place, and which is accepted by the poor themselves. However, education is seen as a legitimate route out of poverty. People perceive that HWWS is costly. This appears to be a misperception because in fact HWWS can be done quite cheaply – a piece of soap can be bought for 100 Shillings, and water is generally available, although they may not be close-at-hand at the times critical junctures occur. Nevertheless, many people have drying racks, which are commonly placed in courtyard, with soap and water there. They may not be currently thought not to be useful for handwashing. A number of beliefs hinder HWWS. For example, Buganda and Busoga traditions suggest that you should never wash your hands before handling a child. Diarrhoea is not seen as dangerous; it is normal, related to tooth eruption or nutrition/weaning rather than handwashing. Many people think that being clean is admirable, but others see it as being too proud and showing off, giving yourself airs. Children also have a number of beliefs about soap which prohibits their use of it, and most do not like the smell of scented soap. The intervention programme must probably ignore these hindrances because they are contradictory to handwashing practice, and cannot be easily changed.


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SECTION FIVE: Recommendations What is now known about the practice of handwashing with soap in Uganda from this formative research can be used to develop recommendations for the National Handwashing Programme communications campaign. Table 9.1: Recommendations for the HWWS campaign 1. Reaching school-children through communication should be through radio messages in the evening when they

have free time and are at home. 2. Radio is the most important form of mass media for mothers, however, it will need saturation coverage and a very

distinctive approach if it is to make a difference 3. In order to reach those who have no access to communication channels, the campaign will have to have a strong

‘buzz factor’. In other words it must be so surprising, intriguing, unusual or attention-grabbing that everybody will be talking about it.

4. Since health workers are regarded as being disdainful, they may not be the best vehicles of hand wash messages in communities

5. Linking the campaign to epidemics like cholera will be unsustainable because once the epidemic has gone so will the practice of handwashing.

6. Find way to involve teachers and children in school handwashing programme, e.g., by giving them specialized tools/materials they can get excited about

7 Ugandans are quite religious and have high cultural emphasis on being good and cooperative. This set of beliefs can be used to advantage.

Table 9.2: Ten great ideas to get moms to wash hands with soap 1 Convince soap-makers to cut bars into smaller, 50 Shilling sizes specifically for handwashing. 2 Children should be directly involved in the design or implementation of the programme. They can be enthusiastic

ambassadors for change and the future. 3 Convince people that their traditional ‘drying racks’ can be used as handwash stands at critical junctures. 4 If we can link clean hands to being ‘smart’ or ‘bright’, might work for school-children (although not necessarily

with respect to critical junctures specifically). 5 It is vital for the campaign to relate to people’s perceptions of themselves, for example, a ‘peasants like me’ who

dig for a living 6 Convince people that soap is affordable 7 ‘84% of Ugandans believe it is good to wash hands with soap’ (people believe it is good to wash hands with soap,

but don’t currently do it; if people learn that their peers think they should be washing their hands with soap they may begin to do it)

8 Disgust-comfort complex could be used 9 Handwashing with soap has clear, immediate benefits: hands feel/smell good, become soft, you feel good as a

result. 10 Challenge; Try the soap habit for 7days Table 9.3: A few great ideas to get children to wash hands with soap 1 Produce a soap with smell that children like 2 Make handwashing fun 3 Produce unbreakable hand wash technology for schools 4 Admired, smart kids become hand wash monitors 5 Making handwashing a moral issue which will get kids fired up to militate for change 6 Let parents know how bad school facilities are so they will militate for change 7 A fun, attention-grabbing campaign about disgusting hands 8 Have children parade through villages, train them as HW promoters.


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APPENDICES

Annex 1: Illustrations for used in FGDs 1) Attraction 2) Status

3) Disgust 4) Purity

I feel attractive when my hands are clen

I would be ashamed if people thought I was dirty, clean people are admired and respected in the community

It is disgusting to think about what is sometimes on your hands

Being clean on the outside can help you feel clean on the inside


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5) Comfort 6) Nurture

7) Fitting in

My hands don’t feel comfortable until I have cleaned them

My children are my pride and joy, I wash my hands to protect them

I wash my hands with soap because it is what every body does


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Annex 2: Materials used in Schools 1) Dairy for Boys


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2) Dairy for Girls


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Annex 3: Data collection Instruments

a) Qualitative Instruments

1) FOCUS GROUP DISCUSSION GUIDE FOR THE COMMUNITY (2 hours)

Moderator Introduction Thanks for agreeing to take part in this research. I am called………………and my colleague is………….. we are from a company called Steadman that works like this all over Africa. This discussion is part of a bigger study into how people live their lives in Uganda. The findings will be used by government to improve programs on family life. Your views, stories, opinions are really important. We are interested in a particular area as you’ll see but will start generally and we want all your views – even when they are not the same. There is no right or wrong answer and everything you say here is confidential – your name will not be attached. The discussion will take at most 2 hours. Any questions. Moderator seek consent (group consent but individuals sign consent forms and also introduce the Tape recorder and seek consent to use it) Objectives • Understand the emotional & social drivers & barriers around handwashing with soap

• Establish the relative importance and collect stories around of each of the following hygiene/hand washing motivators

• Establish the existing/preferred channels of communication

1. DISGUST Dirt, contamination, smells – the things people find revolting, horrible, unappealing, etc.

2. PURITY

Cleanliness, spiritual purity, feeling untarnished.

3. COMFORT How you feel and how your hands feel when they’re clean. 4. STATUS Moving up in the world, being admired and respected. 5. ATTRACTION Attracting future partners, being attractive to your current partner. Looking good 6. NURTURE Doing the best for my children, putting them first - rewarding them, teaching them, helping them develop. 7. FITTING IN Being part of the community, being seen to fit in, belonging, doing what others do.

Respondent Introductions Please tell me: • Your first name, Number of children you have under five years (biological & non-biological), Age, Education level, Marital status & occupation

• Who is in your family and what do they do?

• One thing you do during a typical day you love and one thing you do during a typical day you hate!

Hopes & Fears • What’s your dream about how your life will be and that of your family in future? (For you? For your children?)

• What are all the things that might stop you from achieving your dream or making your dream happen?

• What’s your biggest fear for the future of your family? For you? For your children?

• Does anyone have any different hopes and fears we’ve not mentioned here?

Picture Exercise Explain to the group: • We are going to spend the rest of our time looking at 7 different pictures.

• Each shows a person with a different attitude/feeling about washing their hands with soap.

• We will look at them all then take each one & tell stories from our lives around them.

• OK? (If the respondents are not clear about how this will work explain that it will become clear as we start to work together with the cards & get going!)

Then do the following:

A) Grouping

• Put all pictures down so respondents can see them.

• Give everyone time to look at them.

• Check if there are any they really don’t understand and explain quickly what is going on in the pictures.

• Ask respondents to quickly group the pictures into three categories:

• Yes! That’s so true.

• Maybe it’s true but not that important or not for me.

• No – I can’t identify with that.

• Explain we will look at all of them but will start with the ‘Yes’ ones.

B) Go through the cards one-by-one

1. Pick out one card and show the group.

2. Please explain exactly what’s going on in this picture (make sure everyone understands)

3. Tell me a real story from your own life that in some way fits with what you see here, it may or may not be about hand washing – share some of the

stories, get people to be as detailed as possible.

4. What sorts of people would think or behave like the person in this picture? Why? What about you – why? Why not?

5. Repeat for every card.

Some tips for the interviewer • You must go through all the cards

• Don’t go through them in exactly the same order in each group.

• Spend more time on those grouped as Yes and Maybe but still include all cards

• Make sure stories are ‘real’ not generalized – to check this ask them ‘when was that’, ‘where were you’, etc

• If people find it difficult to think of stories, get them to split into a 2 or 3 for a few minutes and come up with a story from one of their lives between them.

• If people really cannot think of stories ask them why not then move on to the next question.


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C) Individual Ranking

• Give everyone a sheet of paper with all of the cards on it and ask them to pick three that are most important to them and their family and put

them in order of importance.

• Ask each person to share their top one and say a bit about it and why.

• Collect their sheets with their names on for help during analysis.

Some tips for the Interviewer: • We want people’s individual responses here not the group opinion

• Make sure the original Yes/Maybe/No ranking is no longer visible so they do not just copy this

D) Your Community

Ask the whole group: Which of these (7 illustrations) do you think is most important in your community? Why? Which is the least important – why? E) Influencers & Channels of communication Before we end, I’d like to know where women in your community get information on new things, or get new ideas. I will read for you a list of issues and you tell me how they get information on them and give real examples (probe for all traditional methods). • News from within your community

• News from outside your community

• Different ways to look after your home

• New ideas about/ to do with looking after your children

• Things to do with health

• Clothes or make up or jewellery

• New songs!

Summing Up & Thanks • Before we finish was there anything that we’ve talked about today that was really interesting or surprising – what and why?

Thanks!


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2) Behavior trials A) SETTING UP THE BEHAVIOUR TRIALS

i) Recruitment of Caregivers

• Interviewees must not have been involved in the FGDs being conducted.

• Must be willing to participate in the exercise for the duration of 7 days

• Will be available for the duration of the exercise (7 days).

• Must be caregivers of children below 5 years.

ii) Instructions for Leaving Soap

• Half of the households have un-perfumed and half perfumed soap

• Four households given ash/told to use ash for handwashing instead of soap and survey conducted as is

• One bar initially provided per household (more can be provided if requested up during interim visit

ii) Initial Briefing of the Respondent (once recruited)

Ask them to use the soap and water to wash their own hands every day of the trial during each of these moments:

o after you’ve been to the toilet,

o after you’ve cleaned children up who’ve been to the toilet/changed your baby

o before contact with food

o before serving food.

Explain you will come to check that they are doing this half way through.

And that it is their soap so they can do what they want with it as long as they also use it to hand wash.

iv) Interim briefing of the Respondent (after 2-3 days)

• Supply more soap if necessary

• Ask what they have been doing and remind them of the four moments we’re interested in them handwashing

• Ask them to just leave soap where it is before the interview.

B) POST BEHAVIOUR-TRIAL DISCUSSION GUIDE (90 MINS)

INTERVIEW OBJECTIVES

Find out in detail what happened during the week they’ve had the soap.

Understand barriers to and drivers for HWWS in home, particularly:

• Sensory – smell, taste, touch, visual

• Practical - particularly environmental

• Feelings – positive and negative feelings around HWWS.

ONE: INTRODUCTION

• Thanks for taking part in this handwashing with soap study.

• Want to talk to you in detail about what happened while you’ve had the soap.

• Everything you say is confidential – we will not use your name in our reports.

• Some of the questions may seem a little strange! Please answer them as honestly as you can; your answers are really important to me.

• I will want to see the soap in the place(s) (i.e. if someone has chopped it into more than one piece!) it’s been used – I hope that’s OK.

TWO: THE OVERALL EXPERIENCE

• I asked you to use the soap to wash your hands over the last 7 days – please tell me what happened and how you got on? (Allow spontaneous, unprompted comments until they’ve

finished. Then follow up each answer asking for a bit more detail about why they’ve said what they’ve said. For example, you may ask “You said you enjoyed the whole exercise, what

really did you enjoy?”)

• Tell me four things that were good about it (for each ask why it was good)

• Now tell me four things that were not good (for each ask why)

• And tell me two things that surprised you (for each ask why)!

• Did you notice any differences between what you did at the start of the time with the soap and what you did at the end of the time with the soap – tell me a bit more about this?

• Share with me some new experiences or things that you are currently doing different from what you used to do before we started this exercise.

THREE: RAISING AWARENESS OF WHAT PEOPLE DID DURING TRIAL

Now I’d like to know in more detail what happened during the time you had the soap.

a) Yesterday

Let’s begin with yesterday as it will be fresh in your mind. First please describe what your day was like, so:

• What time did you wake up and what time did you go to sleep?

• Take me through what happened from when you got up to when you went to sleep in as much detail as you can remember?

• Now we’ve got a picture of the day, can you remember when during all this you (prompt as necessary):

o Used the latrine? Probe: Were there other times?

o Changed or cleaned up your baby after defecation? Probe: When else?

o Cleaned up after any of your children after they’ve been to the latrine? Probe: When else?

o Prepared food/served food? Probe: When else?

• Now please tell me when you washed your hands during this time:

o Why then? Would that be a time you’d normally do it? If no, ask: Why did it change

o Were there times you used just water? Why and why then?


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o Were there times you used other things other than the soap I gave you (i.e. ash, leaves, other soap products in the house)? When? What made you use them? What made

you use that?

o Which moments did you use soap – tell me a bit about those moments and what made you remember or choose to use soap?

• Were there moments in that day when you thought about washing hands but didn’t – tell me why you didn’t? Also ask: How did you feel when you realized you did not?

• Were there moments where you now think you should have washed hands and just forgot – what made you forget? Also ask: How did you feel when you realized you forgot? What did

you do about it?

b) The Rest of the Week

During the whole time you’ve had the soap; did any days stand out as very different to yesterday when it comes to washing your hands?

o Which day(s) was it? How and why was it so different?

o Were there days where you hand washed more – tell me why this was?

o Were there any days you hand washed less – explain a bit about why?

o Did you use anything else other than soap to hand wash during this time (i.e. ash, leaves) – what did you use? When did you use them? And why did you use them?

FOUR: THE IMPORTANCE OF HAND WASHING WITH SOAP

Here are different times of the day people wash their hands (have each written or drawn - to save on translation and avoid literacy issues - on separate cards):

after going to the toilet at home before worship or church

after going to the toilet outside the home first thing in the morning

after cleaning up child whose been to toilet last thing at night

after changing/cleaning up the baby before leaving the house

before preparing food When you arrive back after having been out.

before serving food after tending to animals

Ask people to do the following…

o Please put these in order of importance and then tell me why you’ve decided to arrange then in that order? (find out what criterion they’ve used).

o Put them into order of which you do most and least – please explain why.

o Which is the most important for people’s health? Why? And which is the least? Why?

o Which is the most important to the health of children under 5 years? Why? And which is the least important? Why?

o These are the most important for health (show those in left hand column – but don’t make them visibly different on cards!) – why are these most critical? This question has

already been asked above

• What else do you know about why it’s important to wash your hands with soap? Do you believe this – why/why not?

• What difference does it make whether or not you use soap – why? Is soap any more effective at preventing illness than other things you may use? What makes you say this? Moderator

to probe for any other things the respondent feels could be a better alternative to soap and probe why.

FIVE: SOAP & THE HANDWASHING ENVIRONMENT

Please take me to all the different places the soap has been since I gave it to you. (If it hasn’t been moved go to current location question) For each ask:

o When was it moved?

o Who moved it?

o Why it was moved?

Was there a location it got used most/least? Where? Why? How do you know?

For current location (this could be more than one if the soap has been cut in half) of soap ask/do the following:

• Please explain why the soap is positioned where it is.

• What’s good about this location for the soap? (prompts: near to toilet/cooking area, clean location, where I always wash my hands, can easily be seen, etc)

• What’s not so good? (prompts: Far from water source, soap gets dirty, can’t see it so don’t remember, kids can reach it, etc)

I noticed that your soap is… (Dirty, hardly used, almost gone, cut in half, etc – any other clear visible change)… explain to me how that is?

SIX: SENSORY BARRIERS & DRIVERS

During the week, did you notice anything good or bad about the following: If yes to any of the following statements, asks the respondent to explain exactly what happened.

o How your hands felt before, during or after handwashing?

o Smell of the soap or the soap on you hands?

o Taste! (i.e. you could taste soap on your food)

o Anything visual about when you washed your hands, or how your hands looked before or after washing, or what went on when you were washing your hands?

What here makes you want to wash your hands regularly with soap - why?

What out of all these would put you off hand washing regularly - why?

SEVEN: CHILDREN & OTHER FAMILY MEMBERS

Did anyone else – who lives here or came to visit - use the soap during this time (prompt for school age children if not mentioned):

o Who? How different is this to what they normally do?

o When?

o What did they use it for and why?

o How do you know they used it for that? (i.e. did they see or are they guessing or were they told, etc)

o Did they say anything about the soap or hand washing – if so what did they say?

EIGHT: EMOTIONAL BARRIERS & DRIVERS

We are going to do some imaginations.

If the soap I’ve given you came to life and could talk, what would it say about the things it’s experienced this week here (allow spontaneous comments first – be patient it may take a while for

the respondent to answer, only if necessary give an example by saying – if I asked the soap in my house it would say “I was so lonely! No one ever picked me up and when they did they put

me down again almost immediately!”)

o The best thing it’s experienced here!

o The worst moment of its time here!

o How it was treated.

o What it noticed about hand washing in this house no one else could possibly know about…

Tell me a little about why you think your soap might say these things. Another game! Imagine we visit two houses in a far off place. In one house the person who cares for the children has been washing their hands with soap as part of their daily routine for 10

years now.


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In the other house, hand washing almost never ever happens – and that has been the case for a long time. I want you to imagine some of the differences between the two (discuss starting with

the house doing hand-washing house then the non-handwashing house):

o What’s the house like? (i.e. What are you likely to see in that house)

o Who is in the family and what do they do?

o What would the mother say is the motto she lives by?

o What would her/his family say about her/him?

o What would be the best thing about going to stay in that home for a month?

o What would be the worst thing about going to stay there?

o How do the children in that home look like?

(Do both then ask…) There were lots/some/no (as appropriate) differences between the two homes you described – please explain to me why this is.

NINE: PROVOCATION & HYPOTHESES

We are nearly done! I have some cards with quotes from other people we’ve interviewed and I want you to tell me what you think about what they’ve said and how their opinions fit with your own: NOTE: Use the sentences from FGD to improve on these

o Show one card and read it out to respondent

o Tell me what was going through your mind as I read that?

o What sort of person do you imagine said that – why?

o Tell me how similar or different your own view is to this and why?

o Repeat for next card (leave out any issues you feel have been raised)

TEN: HAND WASHING WITH SOAP IN THE FUTURE

Imagine I come and visit you again in one years’ time and you are hand washing with soap regularly at the key moments we’ve mentioned on a day-to-day basis. Tell me all the things that have made that possible (prompt for at least 5). Now imagine I come back in one year’s time and you are not hand washing with soap or only hand wash with soap as much as you did before we met. Why might that be? What will have stopped you developing a hand washing habit (prompt for at least five – if not mentioned ask about cost of soap). Finally what do you imagine will happen to the soap we have given to you after I have left? Why? How likely is it that it will get replaced – why? Why not?

THANK RESPONDENT AND END INTERVIEW


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3) In depth Interviews

Setting up t h in-depth interviews (1Hr)

Objectives 1. Explore their perceptions and opinions on the drivers, barriers and motivators for handwashing in the community

2. Establish current and future roles of respondents and their institutions in relation to promoting handwashing.

3. Establish communication channels used

Moderator Introduction

• Thanks for agreeing to take part.

• From a company called Steadman that works like this all over Africa.

• This discussion is part of a bigger study into how people live their lives in Uganda – your views, stories, opinions are really important.

• Are interested in a particular area as you’ll see but will start generally.

• You have been selected as a key informant who has got a wealth of knowledge on issues to do with behaviour in the community

• Everything you say here is confidential – your name will not be attached.

• Any questions.

Respondent Introductions Please tell me: Your first name, Title, Level of Education, Occupation, Age, Marital status Section A: respondents’ own perception on hygiene

1. When I mention the word “hygiene”, what comes to mind?

2. What are the most important hygiene priorities for you and your family and why

3. Rank the priorities in order of importance

4. Can you tell me the benefits of handwashing with soap

Section B: Perceptions on community handwashing practices 1. Tell me about the general hygiene in this community

• What is good and why

• What is bad and why

• What needs improvement and why

2. In your opinion do people in this community think handwashing is important?, why

3. Do people in this community think handwashing with soap is important? Why?

4. What are the key handwashing times for most people in this community? why

5. What are the barriers to hand washing in this community (probe for time, water availability, knowledge, soap availability etc)? Why?


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b) School Tools 1. Structured Observations in schools Objective: ♦ Record hand washing behaviors of 20 boys and 20 girls after using the toilets

Instructions ♦ The exercise will be carried out by 2 researchers i.e. male ( to observe boys) and female (to observe girls)

♦ Arrive 1 hour before the break time on Monday morning

♦ Introduce yourself and your team to the head teacher or the teacher in charge of the school

♦ Tell them that you are conducting a study on the environment of schools across Uganda

♦ Show the ethical clearance letter from the Ministry of Education (DEO) if needed

♦ Tell them that the research will take about three weeks in total out of which you will spend one week full time in a classroom (Upper and Lower) and asks him/her to identify the two

classes

♦ In consultation with the head teacher and teachers decide on the classes you will spend time in (one upper class and one lower class).

♦ Then ask for permission to make observations around the schools- toilets, handwashing facilities, observe 40 children (20 boys and 20 girls) after toilet use. (Do not give them time to

prepare)

♦ Position yourself where you can see/observe the child coming out of the toilets (if different taps/points, stand to the one closest to the toilets).

♦ It has to be a place where you can see the children entering and exiting the toilets. A man will be watching out for boys and a woman will be watching out for girls. (See section 2)

♦ Observe 20 girls and 20 boys. If the observation takes time during the break time and several children come out of the toilets at the same time, then pick one and follow behavior.

♦ Always use a blue pen, any other colours or writing instruments will be refused.

♦ Put a ring round the correct response. If you make a mistake, cross it through once and ring the correct response

♦ Only record what you see and not what you are told.

♦ Only one response is allowed for each question.

SECTION 1: IDENTIFICATION 1.1 Which toilets were you observing from?

Girls = 1 Boys = 2 Mixed sex = 3 Other = 4

IDTOI

1.2 Identification number of observer |__|__|__|__|

IDOBS

1.4 Date of visit D|__|__|.M|__|__|.Y|__|__|

DAVIS

1.5 Arrival time |__|__|.|__|__|

ARRTI

1.6 Observation start time |__|__|.|__|__|

STATI

1.7 Name of school 1.8 Observation complete time |__|__|.|__|__|

FINTI

1.9 Is there soap? Yes/No 1.9 If there is soap, what is it?

Hard soap (if you know the brand, please write it) = 1 Liquid soap = 2 Omo soap in water = 3 Other = ……………………………………..

1.10 Where is the soap? Child brought from classroom =1 Soap by toilet = 2 By the handwashing facilities if facilities far from toilet = 3

1.11 What kind of handwashing facilities are there? Tap = 1 Water bucket =2 Other = 3

1.12 Where are the handwashing facilities situated? Handwashing facilities outside the cubicles (inside the toilets) = 2 Handwashing facilities outside of the toilets = 3 Others = 4……………………………………………………….

1.13 Was there water in the handwashing facility when you were there? Yes = 1 No = 2


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SECTION A OBSERVATIONS OF STUDENTS LEAVING TOILETS DURING BREAK TIME Instructions: fill out for all children leaving the toilet until you get 20 boys and 20 girls. If you miss whether they WH, fill in ‘didn’t see’. It is very important that you record all people leaving. Observing girl/boy

Child Tick====== ========== ======== ===== ==== Handwashing with water only

(HWWO) Rinse one hand with water only

Rinse one hand with soap

Handwashing with soap and water

Do not hand wash Official use

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

2. GUIDE FOR DRAWING EXERCICE

OBJECTIVE

This exercise will be useful for putting handwashing behaviors into schools context • Get children perspectives on handwashing practices of fellow peers (school children)

• The interest is about handwashing with soap after toilet use and before eating

QUESTIONS (things to keep in mind that this exercise could discover) ♦ What is happening regarding handwashing in schools?

♦ Do they consider handwashing even as a risk practice?

♦ What do children do regarding handwashing? If no water and soap what do they do?

♦ What do children consider as barriers to handwashing in schools?

♦ Which moments do children think are critical for handwashing or not?

♦ Is there any mention of the access/utilization of soap or others?

Instructions Briefing Two days to the drawing exercise

• Explain to pupils that this is an important exercise and that their contribution will help to understand why and how to get pupils in the whole of Uganda practice handwashing.

• Tell children that their roles are important because:

Their class is special and has been chosen amongst other classes. They represent the views of the whole school This is their school and they know it best than anybody Through their eyes, they can see things that we adults cannot see and we need to understand what they have to say about the topic and also adults may not see

what they consider important. ♦ Insist on the fact that they should not be influenced by peers, teacher, head teacher and parents and give their own opinion. ♦ Inform them that they have to respect people’s intimacy. ♦ Reassure them that there will be no sanctions from the head teacher and teachers on the drawings. ♦ These drawings will not be shared with people of the school and that the head teacher and teachers will not see these drawings. ♦ Tell the children not to write the names of the people that they are drawing about. ♦ Ask the children themselves to investigate behaviors of fellow peers with regard to hand washing and report them in a drawing format (Young hygiene detectives).

♦ Inform the selected children that they observe their peers during the week and note risky practices related to hand washing which they will report in form of drawings.

♦ The emphasis should be around the children’s behaviors and no on the children themselves.

♦ The observation could also be on head teachers, teachers, teachers, cleaning ladies, guards and prefects

♦ The drawings should capture/depict an action they have seen/observed amongst their peers.

Day of drawing ♦ On the day of drawing, give each child in the study classroom (a selected class in lower primary) a piece of paper/pencils and crayons to illustrate/draw the observed

handwashing risk behavior among their peers.

♦ Allow 20 minutes for the drawing exercise.

♦ Inform children not to write the names of the persons they have drawn.

♦ Tell children to write their names, age and sex at the back of the drawing.

♦ Inform the children that they will keep pencils, colors and crayons after the exercise (they will be theirs).

Selection for debriefing • After the whole class has participated in the exercise collect all the drawings for boys and girls separately.

• Select randomly 20 drawings (10 for boys and 10 for girls) by picking one after every three drawings.

• Invite the children whose drawings have been selected for individual debriefing.

• The debriefing will be done on the same day to allow best recollection of memories of what they did.

Individual Debriefing • Hold individual sessions with the selected children explaining every single drawing.

• The debriefing should take into consideration the following.

Exact description of the behavior/practice in question Exact description of the characters/individuals involved (age, sex, class) Exact description of the time of the day when this risky behavior took place. The debriefing should be confidential and should not be a group exercise. Do not allow teachers in during the exercise ( both drawing and debriefing).


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3. GUIDE FOR PHOTO EXERCICE

Objective To put handwashing behaviours into schools context. It will help in getting children’s perspectives on handwashing practices of fellow peers (school children). Instructions

• The exercise is for one upper class (5/6) • Ask pupils themselves to take pictures (Young hygiene detectives) of what they consider risky behaviours/practices related to handwashing. • Inform pupils that emphasis is on pupils’ behaviours and not on children themselves. • Inform the pupils that they are not restricted if they have something to say about head teachers, teachers, cleaning ladies, guards and prefects. • Inform them that the photographing can catch an action on the spot or something missing in relation to hand washing. • Select Four children (2 boys and 2 girls) from the class room (use voting system- boys vote boys and girls vote girls). Training for the exercise • The training of the detectives will take place in the school. • Remind pupils why they have been selected and what they will be doing in the exercise (to photograph risky handwashing behaviours among peers in the school) • Re-assure selected pupils that this is an important exercise and their contribution will help to understand why and how to get pupils to adopt handwashing with soap. • Tell them that they should reveal as much as possible • Inform them that their roles are important because :

They have been chosen amongst other pupils. They represent the views of the whole school This is their school and they know it best than anybody Through their eyes, they can see things that we adults cannot see and we need to understand what they have to say about the topic and also adults may not see

what they consider important. Insist on the fact that they should not be influenced by peers, teacher, head teacher and parents and give their own opinion. Insist on the fact that they have to respect people’s intimacy and not take pictures of people in action (e.g. in the toilets (naked) and also of adults around. Reassure them that there will be no sanctions from the head teacher and teachers on the pictures that they will take. These pictures will not be shared with people of the school and that the head teacher and teachers will not see these pictures.

• Teach them how to use the camera and let them practice taking photographs • Tell them that the exercise starts Monday and ends on Wednesday • Tell them that the cameras should be kept at schools at the end of each day( should be handed over to the researcher) • At the end of the training give pupils cameras to start the exercise • Pick the cameras on Wednesday evening and take the films for development and printing Debriefing • Debriefing should take place on Friday of the same week • Conduct Individual sessions with the four pupils explaining every single photo. Each detective will be given an opportunity to explain their own pictures to the researchers. NOTE: Record the descriptions for each photographer. During the debriefing sessions consider the following:

♦ Description of the behavior/practice in question ♦ Description of the characters/individuals involved (age, sex, class) ♦ Description of the time of the day when this risky behavior took place.

4. Diary Exercise

Children will be given a friendly diary format and will be asked to record activities in one full day of their lives. This method may be useful to record children feelings, which may be too embarrassing or challenging to conduct in an interview setting.

Objectives: • To learn to connect with primary school pupils in Uganda and get a clearer picture of their lives outside and inside schools. • Provide an opportunity to highlight the issues and experiences important to their own lives, providing insights into daily routines and interactions with family members, school

friends and out of school children. • To understand the agenda of children’s lives in Uganda (recording of 24 hours in the life of a child)

Instructions

• Select four pupils per school in the upper class (5/6) • Select Four children (2 boys and 2 girls) from the class room (use voting system- boys vote boys and girls vote girls). • Stress to the selected pupils that we want to know everything and we are interested in everything that they will tell us. • Tell them not to worry about the mistakes. • Inform the pupils why they are being selected and what they will be doing in the exercise. • Tell the pupils that the whole class will take part in something and this will be based on skills and ability. • The pupils should not be forced to participate even if selected. They should be asked if they would like to participate in the exercise. Note: The important skill here is writing skills and also ability to share life details and not necessarily the best pupils but the ones who can be detail their experience through the day and are good at story telling.

Training of the dairy users:

• Explain to the pupils that this is an important exercise and that their contribution will help to understand why and how pupils spend their day in Uganda. • Tell them that they need to reveal as much as possible and that this is a serious topic and their contribution is crucial because we need to find out how best to communicate to

them. • Tell them that their roles are important because :

They have been chosen amongst other pupils. They represent the views of the whole school This is their school and they know it best than anybody Through their eyes, they can see things that adults cannot see and we need to understand what they have to say about the topic and also adults

may not see what they consider important. Note: Tell the pupils that they should not be influenced by peers, teachers, head teacher and parents and give their own opinion. • Reassure them that there will be no sanctions from the head teacher and teachers on the diaries that they will write. • Tell them that the diaries will not be shared with people of the school and that the head teacher and teachers will not see these diaries. • Tell them that the diary should be filled by the selected pupil • Give the selected pupils to start the activity • The diary should be given for 24 hours

• Tell the children that they are free to decorate the diary format to represent themselves (add pictures, colors, use different pens)

• Collect the diaries after 24 hours and have individual debriefing sessions with participants to explain the activities indicated in the diary.

5. Money game exercise (Kid cool “Wakabi” Ug x) Children will be given a fictional 20,000 UGsh note (a photocopied black and white version of the real note) and then they will be asked to imagine what they would do with that money.

Objective:

To understand and define the notion of cool and non-cool from children’s perspectives in Uganda.

Instructions The exercise will be carried out in the upper class (5/6). Select Four pupils (2 boys and 2 girls) from the class room (use voting system- boys vote boys and girls vote girls). Tell the pupils that that we would want to know everything that they would do with the money and that there will be no sanctions. Tell them that they should not worry about mistakes. Tell them that we are interested in understanding through the things that they buy what they cherish and what their aspirations might be within a realistic context. Tell the pupils that the whole class will take part in something.


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Note: The children should not be forced to participate even if they have been selected. Their consent should be sought before they participate in the exercise. Training

♦ Explain to the pupils that this is an important piece of research and that their contribution will help to understand what children want and aspire to be in Uganda. They will be told that this information will be used to improve communication with children in Uganda.

♦ Tell the pupils that their roles are quite important because:

♦ They have been chosen amongst other pupils. ♦ We need their points of view and this is important for us. ♦ They should feel free to express their opinion.

♦ Tell them that they should not be influenced by peers, teachers, head teachers and parents. ♦ Reassure them that there will be no sanctions from the head teacher and teachers on the information they will write. ♦ Tell them that the formats will not be shared with people of the school and that the head teacher and teachers will not see these forms. ♦ Give the “Wakabi” format to the pupils for a period of half an hour to record things that they will buy using the money. ♦ Tell them that they can buy anything of their choice using the money. ♦ Take the selected pupils to a separate place from other children, ideally in another classroom that is empty (lower primary). ♦ The whole exercise will take about 2 hours (half hour for filling in and one hour for debriefing). If possible the two researchers (male and female) should participate in this exercise. ♦ At the end of the exercise conduct a group debriefing ♦ Conduct a group debriefing with all the pupils involved in the exercise to talk about the different articles and explore on getting a more precise group definition of cool. NOTE: The discussion should be conducted jointly with the 4 pupils but the male researcher prompts the boys and the female researcher prompts the girls regarding the various choices. 6. Behavior trial for primary schools

Provide hand washing facilities for whole school or to the two class rooms Provide non-perfumed soap in the first week and perfumed soap in the second week Support children in the school to run a handwashing campaign Guide the pupils in the two study classrooms to design the posters and banners that will be used in the school campaign to remind their friends in the schools to handwash with

soap. Researcher visit each classroom accompanied with the head teacher mainly to explain to the pupils the objective of the week and to remind them about the importance of hand

washing. Provide guidance on how to use the hand washing facility. Posters about hand washing can also be distributed in each classroom.

Evaluation of Behavioral Trial:

At the end of the second week, evaluate the behavioral trial Individual debriefing with children

Children in the upper class (5/6) will participate in the evaluation exercise. Give each pupil in the entire class an individual debriefing form. Tell the pupils to write one thing they liked and one they didn’t like about practicing handwashing with soap. The exercise will take half an hour Collect pupils’ individual form for analysis

NOTE: Only the researcher should supervise the exercise and pupils should not write their names on their debriefing forms. 7. Drama-focus group A group debriefing will take place in the form of a drama - focus group. Children will do some role-play and simulate a national press conference where they will act out as government officials from Uganda and other children act as skeptical journalists.

Instructions Identify 5 pupils to act as government ministers (various ministers of health, education, finance, gender etc) to advocate for new behavior (handwashing with soap). Identify 5 pupils to act as skeptical journalists who will advocate against the new behavior (handwashing with soap).

Training Tell the pupils selected as government officers that they have a task of gathering various arguments from their friends and peers in the school advocating for the

advantages (drivers) of the introduction of the new behavior Tell the pupils selected as skeptical journalists that they have a task of gathering disadvantages of introducing the new behavior (handwashing with soap) in their school

(challenges/barriers) Organize the pupils to hold a lively discussion of one hour and a half in front of the participating upper class. The discussion should be tape or video recorded then transcribed and translated in English later.

8. Debriefing with adults • Researcher give individual debriefing forms to the teachers in the participating classes to get their opinions about the week’s experiences on drivers and barriers to

handwashing with soap. • Collected the forms for analysis.

9. In-depth interviews

• Conduct in-depth interviews with the head teacher and the two class teachers for the study classrooms (upper and lower). The focus of the in-depth interview will be on: Their experience with hand washing Drivers for handwashing with soap Sustainability of the behavior

In-depth interviews for Teachers Conduct in-depth interviews with the head teacher and the two class teachers for the study classrooms (upper and lower). The objective of the interview is to:

Explore their experience with the hand washing exercise in schools Assess their opinion on the drivers and barriers for handwashing with soap Explore their suggestions on sustainability of the behavior (HWWS)

1. Tell me about the handwashing in your school before the campaign

2. Tell me about the handwashing campaign in your school

• What did you like

• What didn’t you like

3. What did the Pupils say about the exercise?, others

4. What do you think were the factors that contributed to success of the campaign, why

5. What were the things that made it difficult, why?

6. How can we overcome these problems?

7. Do you think this behaviour can be sustained in your school, why?

8. How can your school maintain supply of soap for handwashing?

9. How can your school maintain supply of water for handwashing?

10. Suggest ways through which HWWS can be sustained in your school? 11. Before we finish was there anything that we’ve talked about today that was really interesting or surprising – what and why?

THANK YOU


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FORMATIVE AND BASELINE SURVEY ON HANDWAHSING WITH … - Formative... · FORMATIVE AND BASELINE...

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