School Handwashing Program (Jan to July update)

INDIA – Grampari/WMG email:[email protected]

The tippy tap is a ‘hands-free’, low cost, water conserving hand washing device.

Innovative Hand Washing for Children Intervention – the Tippy Tap School Program INTERIM REPORT, JULY 1, 2012

A. Recap of Project Need and Objectives:

Diarrhea causes illness and death in hundreds of thousands of children under the age of five in India. Hand washing with soap is key in decreasing incidence of diarrhea and is one of the most cost-effective interventions to prevent diarrheal related deaths and disease. Yet, this life saving behavior is often not practiced and difficult to promote. This project seeks to improve child health by increasing hand washing with soap behaviour among students and leveraging them as agents of change in their communities.

B. Progress to Date:

A hand hygiene awareness program has been conducted in 5 schools reaching 257 children in Satara District in rural Maharashtra, India. Visiting each school six times over the course of the school year, a health education team employed new approaches to promote hand washing including introduction of tippy taps (see graphic), awareness building skits and demonstrations, and teaching of best practices and reinforcing learned behaviours through songs, positive reinforcement and follow up visits. In addition, we attempted to measure project impact by assessing change in behaviour before and after the intervention. Pre and post hand washing rates were observed, hand hygiene was monitored for the duration of the project and the number of tippy taps build in homes were all used as metrics of success. Analysis of these data is currently underway. Based on the results, recommendations will be made and disseminated at the local, state and international level via manual and other materials. Details are below.

0. Target School Identification

5 schools were identified for this pilot project on the basis of teacher cooperation and ease of observation. These schools are shown in the map below.

Map showing location of schools as well as Grampari/WMG Office.

Grampari/WMG

Ruighar

Katewali

Darewadi

Nagewadi

Ambral

2.08 mi


1. Baseline Data Collection

To observe pre- and post-intervention hand washing behaviour, staff members were trained in data collection methods. We found that the best method, taking into account field staff capacity, available resources and school regulations, was hidden and or unobtrusive structured observation; field staff would sit at the school for several hours and measure hand washing rates in relation to toilet use and mid-day meals. School staff members were not told the specific purpose of the survey but were told it was a general survey to measure access and use of water and sanitation infrastructure at the school in order to avoid teacher bias. Data sheets were created to record observations. In some cases, field staff were in unobtrusive locations, such as across the road from the school. In other locations we also tried hidden video cameras to reduce impact of the observation on behaviour. Baseline Data Collection was performed for all five schools.

2. Awareness Building

After initial data collection, we conducted a 3 hour program at each school to introduce the subject of handwashing. While each program was tailored based on our observations from Phase 1, the programs all covered ‘WHY, WHEN and HOW’ we wash our hands using skits and interactive methods detailed in our initial proposal. The program involved our team building a permanent tippy tap near the school latrines, tippy tap building competitions for the students as well as the election of student ‘health ministers’ to ensure that the tippy tap was maintained and used properly. Awareness Building has been done for all 5 schools.

Nagewadi children practice a simple song that ensures that they wash their hands properly and that they have fun doing it.


Newly elected student health ministers from Nagewadi, one for each day of the school week. These ministers monitor hand hygiene daily for all the students as well as ensure the tippy tap has soap and water.

Students from Ruighar wonder if they might be the winners in the tippy tap building competition during an awareness building event.


3. Reinforcement

Several strategies were employed to reinforce the hand washing lessons; while the tippy tap is a practical and fun device that engages children and adults alike, this technology ‘pull’ had to be combined with a behavioural ‘push’ to try and ensure long term behaviour change. To this end, our team performed 6 follow-ups for each school to reinforce the message. Videos, colouring contests, posters, games, skits performed by our team as well as the children were some of the tools used. The goals were to incorporate different elements of behaviour change such as disgust, peer pressure, group affiliation and rewards for positive behaviour. After each school visit, we went to the home of each student who had built a tippy tap during the program. This helped to a) recognize positive behaviour, b) ensure the quality of each tippy tap and c) engage the family in order to

spread the message. This has allowed us to build multi- generational relationships in each village, something we hope to leverage in future community-wide programmes.

Varsha from Ambral finds her name on the ‘Hand Washing Champions’ chart to place her star sticker during a followup visit. Also seen are the winning entries from the handwashing coloring competion.

Akash and his brother Abhay from Ambral show off the tippy tap they built at their home.


4. Assessment:

Observation at the end of the follow up has been conducted for 4 of the 5 schools. We were unable to do the Katevali School post observation as the school schedule changed and no longer provided lunch meals for the children. The methods had to be modified from those used in Phase 1 since the handwashing team was at this point, clearly associated with handwashing and could potentially influence behaviour. Data will be summarized and analysed in the upcoming months. However, even during the course of our visits, we have seen an improvement in hand hygiene. Details of the school and tippy taps built to date at student homes are given in the table below:

School Location Students* Target Household Tippy Taps**

Tippy Taps built and maintained as of last followup

Ambral 35 27 27

Darewadi 55 37 7

Katewali 35 29 4

Nagewadi 63 40 14

Ruighar 69 53 25

* While our initial proposal estimated a reach of 400 students, we’re actually working with only 257. The schools

with the larger numbers proved extremely difficult during the observation stages especially with new staff and we

wanted to ensure high quality data sets especially at the start of this project.

**One way we evaluate program impact is to see how many tippy taps are built and maintained by the students at

their homes. Many students at a school are related and thus the number of tippy taps that could be built is

different from the number of students.

Navin, age 8, worked with his family to build a tippy tap at home.


5. Documentation and Dissemination: Over the next few months we will be compiling our extensive field note. A draft manual has been started and will be refined with the final impact assessment. Our team also met with the Secretary to the Chief Minister of the State of Maharashtra who would like to see the tippy tap in all 4000 schools in Satara District. We will be working on a strategy to take this forward.

C. Conclusion: We’re continuously refining the project based on our field experiences. Some of the challenges to date include recruiting staff with the right skill sets, school summer holidays condensing our followup schedule, getting teacher cooperation and requiring multiple home visits to ensure we can meet with family members. Our biggest challenge was known prior to the start of this project – observing hand washing behaviour without influencing it is difficult, especially with limited resources. One of our favourite and most effective techniques is having field staff pose as bird watchers or road survey workers to allow us to observe from a distance, as well as wearing dark glasses, wigs and hats! We have overcome most of these challenges and the project is showing some exciting results even at this stage. Ambral for example has 32 tippy taps – every single student built a tippy tap in their home and a few went to neighbouring villages and built some for other families! A casual school visit by a senior education official during one of our school programs has resulted in interest in expanding this program at the district level as mentioned above. We’re excited to share more of our progress during our final report and try to push the envelope on small-scale hygiene promotion programs worldwide.

Sowmya Somnath, P.E. WASH Progam Director WMG/Grampari

Nagewadi school is in the foreground. The black circle indicates the location of our “bird watching” hand hygiene observer who is using binoculars to observe handwashing that is occurring at the tippy tap and water tank at the front of the school.

School Handwashing Program (Jan to July update)

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