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Behavior Change Communications (BCC):

Hygiene Promotion through Community and

Schools

Case Study Research Report



³But today I can recognize that events back then were part of a life-long pattern in whichthinking and doing have either come together or failed to come together ± I think, I reach a

conclusion, I turn the conclusion into a decision, and then discover that acting on the decisionis something else entirely, and that doing so may proceed from the decision, but then again it

may not. Often enough in my life I have done things I had not decided to do. Something ±

whatever that may be ± goes into action; ---I don¶t mean to say that thinking and reaching

decisions have no influence on behavior. But behavior does not merely enact whatever has

already been thought through and decided. It has its own sources, and is my behavior, quite

independently, just as my thoughts are my thoughts, and my decisions my decisions.

The Reader,

Part I Chapter VBernhard Schlink ( translated from the German by Carol Brown Janeway)



Contents

About the Research Team 04

Acknowledgements 05

Acronyms 06

1. Introduction and Overview 07

2. Formative Research, BCC Strategy, and Channel Identification 09

3. Message/Material Development 13

4. Design and Implementation of Training 15

5. Behavioral Change against Project Objectives 18

6. Behavioral Impact from Integrated BCC Approach 27

7. Conclusions and Recommendations 39

Annexure 42Table: Self reported / observed behavior

Table: Adoption of new behaviors per site



About the Research Team

Ms. Khalida Ahson, Lead Researcher, is an independent consultant and has worked for USAID, UNDP, Planning & Development Department, Government of the Punjab, Lahore,

and Inter/national NGOs e.g. Shirkat Gah-Women Resource Centre. She holds a Masters¶

degree in English Literature from the University of the Punjab, Pakistan. She started her

career as a mid-level manager with World Wide Fund for Nature-Pakistan and has held senior

management positions with international development agencies and NGOs like UNDP, Indus

Resource Centre (IRC), Society for Advancement of Education (SAHE), SDC-Civil Society

Human and Institutional Development Program and PLAN. Her particular interest is Human

and Institutional Development and Gender Mainstreaming.

Ms. Rohina Iqbal, Research Assistant, is working with Association for Gender Awareness

and Human Empowerment (AGAHE), as Project Coordinator and Operations Manager. Her

responsibilities include capacity building of AGAHE staff / community and monitoring of it¶s

programs and projects. Her strengths are her ability to build rapport with the community. She

has done her Masters in Sociology from University of the Punjab, Lahore, Pakistan.



Acknowledgements

The research team would like to thank everyone in the Islamic Republic of Pakistan whoassisted in the case study research and presentation of information included in the final

report.

We would like to acknowledge the partner NGOs or grantee NGOs, located in the selected

target districts for the case study research namely Gujrat-Punjab, Sukkur-Sindh and

Rwalakote-Azad Jammu and Kashmir. This includes the partner NGO based in Okara where

the case study research tools were pilot tested. The field work could not have been a success

without the cooperation, accommodation and hospitality of these partners. It is pertinent to

mention that these organizations/key channels received training/orientation and served as aresource for training and behavior change in others.

We would like to acknowledge key participants of the Focused Group Discussion, In-depth

Interviews and Semi Structured Interviews, critical to the success of the work, with the

consideration, that it would be quite impossible to appropriately acknowledge them for thesake of confidentiality.

Finally, it is important to recognize that the behavior changes and health effects resultingfrom the work in Pakistan are attributable to the tireless work of a team of communityhygiene promoters committed to improving the health of their communities.

The author regrets any errors or omissions.



Acronyms

KP Khyber PakhtunawaFATA Faderally Administered Tribal Areas

AJK Azad Jammu and Kashmir

BCC Behavior Change Communications

BCS Behavior Change Strategy

TIPs Trials if Improved Behaviors

PC Project Coordinator

CHP Community Hygiene Promotion

SHP School Hygiene Promotion

CHP Community Hygiene Promoter SHP School Hygiene Promoter

HP Hygiene Promoter

PPP Public Private Partnership

NGO Non-Government Organization

CBO Community based OrganizationIRC Interactive Resource Center

IRB International Research Board

SSI Semi-Structured InterviewFGD Focused Group DiscussionIDI In-depth Interview

NA Not Applicable



1. INTRODUCTION AND OVERVIEW

1.1. Setting the stageThe Pakistan Safe Drinking Water and Hygiene Promotion Project (PSDW-HPP) assists local

governments and communities to safely maintain and operate water treatment (purification)

systems, as well as to promote good personal and household water hygiene in order to

maximize health benefits. The Academy for Educational Development (AED) is primarily

responsible for the hygiene promotion component of the project. Under this component, the

approach is to target parents of children under five to reach large scale primary audiences

with behavior change messages and activities to create sustainable improved hygiene

practices.

1.2. Project Scope, Case Study purpose and Project Objectives

The hygiene promotion component of the project aims to assist communities in 28 districts

for Community Hygiene Promotion (CHP) and 40 districts for School Hygiene Promotion

(SHP) component in Punjab, North West Frontier Province (NWFP), Sindh, Baluchistanincluding Federally Administered Tribal Areas (FATA) and Azad Jammu and Kashmir

(AJK) to promote good personal hygiene and safe drinking water practices in order to

maximize health benefits.

Case Study Purpose

The purpose of this case study is to

y Conduct research aimed at gaining insights into the school and community hygiene

promotion project components and how they work together in an integrated fashion

towards behavior change at the household level.

y Gain an understanding of how the program is impacting the communities it serves and

those involved with regards to:o Sustainability ± of the model that is being used i.e. involvement of NGOs,

private sector, and key channels, such as mosque Imams, respected women

from the community, physicians, etc.); and

o Behavioral sustainability within target groups (families ± mothers and fathers

of children under the age of five) as a result of exposure to the Project¶s

behavior change communication approaches and technologies.

Project Objectives

Objective 1: To Build the Capacity of Partners to Implement the School Hygiene Promotion

Program

NGOs trained in the school program

Teachers trained in the school curriculum



y Hand washing with soap before eating

y Hand washing with soap after toilet

y Air drying of handsy Hand washing with soap of younger siblings¶ hands and air drying

y Take soap and water to mothers prior to meals

y Assist mothers with solar heating of water

y Ask parents to buy soap

y and also sharing lessons learned related to hygiene with siblings and parents, assistingyounger siblings and parents with the above doable actions and taking home calendar

(material) to mother.

Objective 5: To Build the Capacity of Partners to Implement the Community Hygiene

Promotion Program/Involvement of Key Channels in Promoting Improved HygieneBehaviors

Objective 6: Community Hygiene Program Implemented in Targeted Districts

Objective 7: Improved Hygiene Behaviors at the Household Level

1. Improved hand washing behaviors, Hand washing with soap at multiple criticaltimes (self and teaching children to do so), Air drying of hands

2. Hand washing stations set up at the household level (two places), HW station set upnear kitchen, HW station set up near latrine, Provision of soap at both locations

Objective 8: Improved Hygiene and Safe drinking water Behaviors at the Household Level

1. Adoption of at least one water purification method, Households obtain water from

filtration plant, Households appropriately purify water by boiling, Solar filtration

2. Improved water storage at the household level, Drinking water kept in clean, raised,covered containers, Water taken out of container through tap, long-handled scoop, or

poured from a narrow-necked container

Objective 9: Develop radio spots for airing and use other Mass Media approaches in support

of program activities



y Orient and follow-up key influentials i.e. mosque Imams, women volunteers, physicians, NGOs and CBOs.

The CHPs are assisted by the PC in all of the above. The CHP team is mentored andmonitored by project staff and consultants.

The CHP comprised the following activities:

Mother and fathers¶ gr oup sessions

Mother¶s /father¶s session are arranged by the HPs hired under the project by Grantee NGOs.

During the activity an orientation on key messages of PSDW-HPP is given to 8-10

mothers/fathers with children under five from a specific mohalla (colony) in the field,

through a pictorial flip chart. The project criterion to conduct BCC is in specified tehsilswhere Government of Pakistan has installed or plans to install filtration plants, Union Council

is then selected on the bases of where filtration plant is installed in a tehsil. The orientation is

conducted by HPs, trained by consultants, whose training was arranged by PSDW-HPP

before implementation in the field. The HPs are provided with a Guide to conduct a

mothers/fathers session and other resource material, principally a flip chart with appropriate

picture illustrations, which is instrumental in conveying the messages to mothers/fathers

effectively. Other activities held under the CHP component augment the session e.g. hygiene

melas, and community interactive theaters. The mothers/fathers who are a part of the sessionmay attend the melas or the theater if they are held near their mohalla. The fathers are given

an identity card holder as keepsake of the session. The mothers and fathers sessions are

reinforced through key influential i.e. women volunteers, mosque Imam and physicians.

Reinforcement is provided to mothers primarily through women volunteers and physicians

and to fathers, through mosque Imams. However, primarily, all key channels are able to reach

both mothers and fathers.

Interactive theater perf ormances in the community

Under this activity, the grantee NGO staff identified and selected community volunteers to betrained in interactive theater. The PSDW-HPP asked the grantee NGOs to select at least 7

such volunteers from the community in each district, however this varied from district todistrict. The selected volunteers were trained by the project through Interactive Resource

Centre-Lahore (IRC) using one of the 8 scripts developed for the purpose. This was a five-

day training. Eight scripts (15-25 minutes) were developed by IRC catering to relevant primary target audience i.e. mothers, fathers and children. The overall performance takes

approximately 1 ½ hour when being performed in front of the community. It is followed by a

discussion at the end to clarify issues and answer questions raised by the audience.

C ommunity melas2



partners put up a main stall at the mela where they arrange practical demonstration of handwashing. They also announce different methods of water purification on the sound system for

the benefit of people attending the mela. Other NGOs, mostly working in the water, health

and education sector, are also invited to put up stalls. There are merry-go-rounds and puppet

shows are arranged for children. Media is also invited to the mela.

Local community-based organization (CBO)

Where a local NGO/CBOs is working in health, hygiene, environment and education sector,

in the same district/tehsil, the partner NGO train the NGO/CBOs and also guide them to

integrate the key messages of the project in their mainstream activities.

Key infl uentials Mo sque Imams: On an average there are 20-25 mosques in a union council. The Imams of

these mosques are given a one-day orientation by the CHP with a desk top reminder with key

hygiene messages. All the messages in the desk top reminder are augmented by a relevant

ayat (excerpt) from the Quran (Muslim Holy book). The desk top reminders are produced in

provincial languages.W omen vol unteers: The CHPs identify active women from the community through mohalla

meetings. The criterion to select the woman volunteers is that they be well respected by other

women of the community. The women are given an orientation session in which a calendar ishanded over to them. They are oriented to give the messages contained in the calendar toother women in their community.

Physicians: The CHPs identifiy medical doctors, preferably child specialist and/or doctorsworking mostly for local women and children. They are given a one-day orientation. The

doctors are provided with certificates to give to model mothers, who nurse their child back to

health from diarrhea or have been conscientious in their child¶s health.

The HPs follow-up the key channels to get feedback on how the hygiene messages are being

adopted by the community.



2.2. The School Hygiene Promotion Program targets boys and girls¶ from grade 4government primary schools as message carriers to their mother/families. The school

program involves 1.) teacher trainings by school hygiene promoters (SHP) and 2.) a ten-week,

interactive hygiene promotion curriculum with fun, take-home exercises that the students participate in and share with their families. The teachers are trained to deliver this curriculum

to the students.

The PSDW-HPP identified grantee NGOs in target districts and trained selected staff under

this component. The grantee staff comprised a project coordinator (PC) and a team of two

(fe/male) hygiene promoters / master trainers. There were two master trainers for each Tehsil

and the PC has the overall responsibility of operations and management in the district. The

PSDW-HPP trained the master trainers. They are mentored and monitored by project staff

and consultants. The grantee staff remained active participants in securing the buy-in of thegovernment education officials to conduct the SHP component in the District. After this

approval was secured, the master trainers identified:

y Government Primary school in the tehsil

y Selected primary school teachers teaching grade 4 students

y Arrange and conduct Teachers Training

The teachers are trained to deliver a ten-week school curriculum comprising 10 activities to

students. The master trainers provide follow-up and guidance to the teacher.

2.3. Public-Private Partnership The PSDW-HPP is working in collaboration with

private-sector partners, such as Unilever to enhance its reach and impact in schools and

communities. Unilever provides soaps, leaflets, posters and experimental germ glow

machines. The soaps were distributed through both CHP / SHP component. The germ glow

machines demonstrations were conducted in schools. Soap and gifts (pencil box, bandanas)

are given to students of grade 4 who had completed the school curriculum. Material was

given to schools for display. Under CHP, the partners distributed the material from Unilever

at melas and theater performances.

2.4 A Mass Media Campaign complements the Project¶s behavior change work through

the communities and schools, reinforcing messages and activities delivered throughCHP/SHP. The PSDW-HPP implemented this program with local FM radio channels. The

grantee partners were informed and given the radio spots so that they could air these duringtheir CHP component activities, particularly, melas. The radio spots were developed in 7

regional languages of Pakistan. There is a longer version of 45 seconds and a shorter versionof 28 seconds.



3. MESSAGE/MATERIAL DEVELOPMENT

A desk review was conducted by the PSDW-HPP during Oct-Dec 2006. This review

identified UNICEF as the most active organization in prioritizing and implementing itshygiene communication strategy in Pakistan. However, the approach commonly used by

actors and stakeholders in Pakistan for hygiene promotion was didactic and communities

mostly were told what to do because it was ³good´ for them.

An essential feature of PSDW-HPP behavior change strategy is that it views the health

problem through a behavioral lens and defines and promotes key behaviors. It fostered a

logical, disciplined and consultative method for selecting strategic actions that are most

essential for promoting adoption of behaviors needed for the desired health outcome ² inthis instance, reduction in diarrhea disease through preventive measures. The behavior

change methodology used in the project fostered behavior change, as opposed to simply

increasing people¶s knowledge. It was based on an understanding of how families think and

behave, the constraints and limitations they encounter, and the reasons they may resist

change. The methodology was developed after a process, which required communityoutreach and broad community participation. It included implementation of trials of improved

practices (TIPs).

The community participation in the process of materials development was enriching. Withregard to graphic materials, it was observed that community prefer illustrations that are

detailed, contain less text, and present ³things they way they should be,´ as opposed to theway they actually are. For example, family was represented, not as they existed in the

community, but as an ideal. The illustration became the model for replication for the target

audience. Two types of graphic products were developed, those intended for use by NGOs

and those aimed at community.

Products for Grantee partners are designed to aid them in interacting with community. These

are:

1. NGO Manual: covering the process and use of the materials

2. Teacher¶s Training Manual: designed to aid Master Trainers in delivering the school

curriculum containing 10 interactive, fun activities to teachers

3. Flip Chart: depicting ideal behaviors, picturing local characters and settings.

Products for community consisted of reminders. These are:

1. Calendar: depicting the action community needs to take to be safe from germs. It wasintended to be posted in the home for mothers, fathers, children.

2. Desk top reminder: for mosque Imams consisting reinforcement of hygiene behaviorsthrough Islamic teachings

3. Scripts: theater scripts suited to target audience i.e. mothers, fathers, children4. Posters: for dissemination/display at filtration plants, schools, CBOs and other venues



10. Activity chart: a weekly planner for students to check practice of hygiene behavior atcritical times

3.1. Research findings

PSDW-HPP was able to develop attention-grabbing and self-explanatory BCC material i.e.

calendars, posters, danglers, flip charts, desktop reminders etc. The BCC material is a huge

success. It was appreciated by both grantee NGOs, target audience and key channels, both for

CHP and SHP component.

The children had particularly enjoyed the school curriculum produced for them. The calendar

was a proud possession and the activity chart was filled with enthusiasm.

The educational topics were intimately linked to the graphic illustration to encourage people

to put the message transmitted into practice. Not only did the project team take considerable

care to generate materials in collaboration with the community, they also put forward a

similar effort to pre-test them. The purpose of the tests was to avoid incorrect or confusingmessages or messages that were inconsistent. The community made suggestions with regard

to the language, positions assumed by individuals in pictures, the use of particular colors, and

items missing from scenes. There are many models of message testing; the one used PSDW-HPP was a measure of audience reaction to the sampling of materials according to variableslike understandability, attractiveness and acceptability.



4. DESIGN AND IMPLEMENTATION OF TRAINING

More often than not, people are prevented from adopting new behaviors by obstacles that

range from lack of necessary technologies or infrastructure (hardware) to personal resistancearising from distrust, disbelief, cultural barriers, fear of innovation, etc. These obstacles have

to be specifically addressed. The PSDW-HPP, made an effort for community hygiene

promoters to attain a high level of interpersonal and counseling skills, so they could gain the

confidence of household members, discuss with them the obstacles that prevent the adoption

of new behaviors, and ³negotiate´ a household strategy for overcoming the obstacles. These

counseling and negotiating skills are indispensable for a BCC strategy to be successful and

play a supporting role by creating a ³garden´ in which hygiene promotion activities can

flourish.

The PSDW-HPP initiative to provide NGOs with support in implementing a hygiene project

included behavior-change approaches to improve their project interventions through the use

of behavior-change communications. The project provided technical assistance in the form of

training to the staffs. Three main training genres were implemented to achieve the above asfollows:

4.1.T

raining of T

rainers

A series of three-day Training of Trainers were conducted on Behavior Change

Communications, at Islamabad prior to the NGO Training. During this workshop LeadTrainers / Technical mentors were prepared to deliver workshops to staffs, hired under the

project, in the selected districts. As these trainers were envisaged to provide training to NGOs

from all the four provinces of Pakistan and AJK, trainers, adept at speaking the regional

languages of Pakistan were selected to attend the training. The first ToT was conducted by

Shahnaz Kapadia Rahat, ECI-Islamabad. As a lead consultant, she has taken forward the

BCC message ± in projects that she is working through her Company, e.g. WATSAN (World

Bank), Enterprise Development (The Asia Foundation), etc. The training also resulted in the

production of Grantees Training Manual, which, three day training was delivered to NGOs,

as part of their preparation to implement the project activities.

T he above mentioned consultant has the ex perience o f working with two AED pr ojects, i.e.

PSDW-HPP and C ommunication f or Avian Infl uenza prevention. F or both the Pr ojects, her

task was t o train trainers, who would take f orward the communication message t o the

community. On the PSDW-HPP, her r ole was t o train national consultants, who then had t o train Grantee Partner NGOs under the pr oject. She was not involved with Ca pacity Building

o f filtration plant em pl o yees, P ublic-Private Partnershi p or media com ponents o f the pr oject.

She mentioned that her overall interaction with the AED coordinat ors and team ( on both pr ojects) has remained very po sitive and pr od uctive, and she was a ppreciative o f the



untrained ones remained a weak area throughout the course of this project. More than90% of grantee NGOs couldn¶t manage to keep their trained staffers intact with the

project which resulted in affecting the quality of implementation.

y For a project aimed at changing unhygienic behaviors of low income, rural, semi-urban and remotely-living communities, one year is a short span of time during whichonly the foundation stone of behavior change has been laid. There¶s a lot left to be

done which should be done in the near future without breaking the continuity of activities. Otherwise, all the hard work done so far may go to waste and desired

results may not be achieved.

y The PSDW-HPP activities were focused in specific union councils, whereas they

should have covered the whole Tehsil

y The target of women volunteer should be at least fifty in each union council, as it is aneffective channel

y Lady Health Worker should have been included as a channel

y The focus of SHP component should not be on grade 4, but on all primary level

students to make it more effective

y Principal / head teacher of the school should be also be provided an orientation or

trained while the grade 4 teacher is being prepared to deliver the school curriculum



5. BEHAVIORAL CHANGE AGAINST PROJECT OBJECTIVES

The goal of the project is to encourage / promote hygiene behaviors which reduce the

prevalence of diarrhea among children under five years of age. These young children are themost susceptible to diarrhea, and the dehydration it causes is life-threatening for them,

especially if they are undernourished. The preventive approach used to achieve the goal was a

hygiene behavior change communications program focusing on hand washing, water

purification and proper handing of drinking water through community and school hygiene

promotion activities. The two types of interventions created a synergy that increased impact

at the house hold level in a district. Third intervention is media which complements these two

activities.

The following narrative gives an analysis of outcomes against project objectives and common

themes emerging from the implementation.

Objective 1: To Build the Capacity of Partners to Implement the School Hygiene

Promotion Program NGOs trained in the school program

Teachers trained in the school curriculum

This comprised training district based NGOs in the school / student activities and curriculum.The NGO staff, thus trained, called Master Trainers, then trained primary level governmentteachers and assisted the teachers in applying the school curriculum with students of grade 4.

The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the

objective: SSI / 3 SHP-PC, FGD / 16 S-HPs, Questionnaire, Interview / 3 Consultants = 22.

IDI / 8 teachers, FGD / 16 HPs, SSI / 3 SHP-PC, SSI / 2 Head teacher/Principal,

Questionnaire, Interview / 3 Consultants = 32

Data Analysis: NGOs were more than adequately trained. AED Training design, delivery,

support activities and support follow-up is more than adequate. The training is innovative.The consultants did a good job of delivering it to NGOs and providing follow-up to NGOs.

The difficulty and negative aspect of PPP implementation were reported by PC and HPsacross districts.

As Sukkur partner NGO has made SHP a part of their education program, there will be

another cycle of it. This was confirmed by Head Teacher-Government Primary Girls/Boys

School, Bridge Colony/Police Colony Sukkur.The SHP implementation in Rawlakote is weak due to not relevant teachers being trained anddifferent schedule of long holidays. The team did not meet the education department

representative in Okara-Gujrat. However, program implementation was strong with activeadopter NGO teams/ teachers / head teachers. The consultants interviewed, are skeptical,

regarding the sustainability of the effort and recommend another cycle of SHP in the districts,



Common Themes

1. Innovation, uniqueness of training design.

2. Excellence of support material

3. Motivation for Change: health benefits and Islamic teaching

4. Barrier: Short Duration of project (6 month project)

5. PPP: difficult, embarrassing and time consuming for NGOs.

Data Analysis: Teachers are more than adequately trained in Punjab and Sukkur. The teachers

are inspired by the school curriculum as it was enjoyed by children. They did not find it

difficult to deliver due to their excellent training and follow-up provided by HPs. The

training is innovative. The consultants did a good job of delivery / follow-up of HPs and HPs provided timely / friendly follow-up to teachers. A good rapport was observed between the

HPs/head teachers and teachers when the team was introduced to the school during field work.

In Punjab the male teacher reported that Activity 8 was difficult for students. In Sindh the

teachers reported that memorizing the poem was difficult because it was in Urdu. In

Rawlakote the teachers expressed difficulty in doing experiments/activities due to one-roomschool. They admitted that they did not deliver the school curriculum as guided by the

training/ HPs due to one-room, single teacher schools. However there are one-room single

teacher schools all over Pakistan, one of which was observed in Punjab, where the teacher had appropriately and conscientiously applied the experiments.

The reason for above weakness in Rawlakote was identified by S-HPs as follows: the AEOdid not send relevant teachers for training, which was discovered by HPs during follow-up. A

rapport was not observed between the HPs and teachers during field work.

The consultant recommend that head teacher/principal should also be trained as part of the

program.

T he PSDW-HPP has br ou ght about change at the level o f the school in that the schools,teachers and children have made changes at the personal / school level thr ou gh their

ex po sure t o the SHP.

PSDW-HPP needs t o make an eff ort t o instit utionalize the school pr o gramme in the

pr ovincial training instit utes f or primary teachers in P un jab, Sindh, Bal ochistan, FAT A, AJK

and NWFP. Each pr ovince has inde pendent training instit utes f or training primary teachers.

In the opinion o f the research consultant individ ual eff orts by teachers / head teachers will

not be enou gh t o su stain the excellent school pr o gram pr od uced by the pr oject f or SHP-im plementation. A different strategy t o work in mountainou s areas could be devised.

Common themes

1. Innovation, Uniqueness of training design.

2 Experiential learning for children



To achieve the above District education official buy-in for school activities was sought. Itwas ensured that the target schools receive official permission to become a part of the

program.


objective: SSI / 2 District Education Department Representatives, FGD / 16 HPs,

Questionnaire, Interview / 2 Consultants = 20

Data analysis: The SHP-NGO introduced the program to the local education departmentrepresentative. They implemented the program with the support of the education department

at district level. This support extended to securing permission from the concerned department,

for the primary fe/male teachers teaching grade 4 in government primary school, to attend thetraining and then deliver the school curriculum in their respective classes. This was achieved

by issuing directives to the schools through Executive District Officer. The respondents

reported that they will take the training forward but could not specify how this will be done

except for taking help from the local grantee NGO.

A parallel plan t o instit utionalize the school activities in the school academic cycle in a

cyclical manner has not been s pecified by PSDW-HPP. T he PSDW-HPP¶s eff orts t o gain

stakeholders support f or SHP im plementation was limited t o securing permission f or training teachers and delivery o f school curricul um. It did not s pecifically seek t o su stain the eff ort,

teacher¶s training design and school curricul um. T he teachers trained have been given 2

f oll ow-up visits in the six-month life o f the pr oject. T his is not enou gh eff ort f or su stainability

o f the pr ocess/ outcome.

Common Theme

1. Change in personal/school level appearance of schools, teachers and children

2. Sustainability efforts: nascent and random

3. Sustainability process: unclear

Objective 3: Ten-Week School Curriculum Administered with Students of Grade Four

The school curriculum with 10 activities developed for students of grade 4, was completed inschool with relevant activities/experiments.

The following Tool / Sources for Cross Reference/ Triangulation were applied to assess theobjective: FGD/ 19 female and 20 male students = 49, FGD/ 19 mothers, IDI / 4 mothers, IDI/ 8 teachers = 80

Data Analysis: Children learnt about germs and how to be safe from them. Children liked

doing the experiments during the delivery of school curriculum of which potato and rice



Children like t o d o things and the ex periential delivery o f the 10 activities pr oved t o be a source o f retention f or them in Okara, Gujrat and S ukk ur. T he ex periments were not d one by

fe/male teachers in Rawlak ote. T hey delivered the syllabu s in a lect ure f ormat.

Common Themes

1. Experiential and Enjoyable activity for children and teachers

2. Sense of achievement for children and teachers

Objective 4: Adoption of Doable Actions Among Students of Grade Four and Sharing of

Information with their Families

The hygiene curriculum developed for students of grade 4 motivated the uptake of followingdoable actions:

y Hand washing with soap before eating

y Hand washing with soap after toilet

y Air drying of hands

y Hand washing with soap of younger siblings¶ hands and air drying

y Take soap and water to mothers prior to meals

y Assist mothers with solar heating of water

y Ask parents to buy soapy and also sharing lessons learned related to hygiene with siblings and parents, assisting

younger siblings and parents with the above doable actions and taking home calendar

(Material) to mother.


objective: FGD/ 19 female and 20 male students = 49, FGD/ 19 mothers, IDI / 4 mothers, IDI/ 8 teachers = 80

Data Analysis: Instead of 1 child responding, the team asked the whole group to respond. All

children participated actively in repeating the key messages. The students in Rawlakote also

recited the messages but were less confident in rendition and looked at each other for

recollection. The children had invented ways to make sure that they were rubbing hands with

soap for 20 seconds. In Punjab they read the 1st

Kalma (Islamic holy script) twice, counted

slowly to 20 in Sindh and Rawlakote. All the students responded that they help siblings. They

responded that they helped mother in Solar filtration. They share the project messages with

cousins and relatives. They ask elders to buy soap. The calendar and activity chart wasdescribed as beautiful and they have both. The activity chart was submitted to male teacher in

Sukkur. Fe/male students had it in their bags in Gujrat and Sukkur. This was observed and

confirmed.

The children in Rawlakote did not remember the activity chart. Teachers corroborated that

households/mothers have adopted the key messages as per sharing of students in Gujrat and



mother with boiling water. This was considered hazardous for children by mothers. Theyhelped in solar filtration.

Mothers were ha pp y by the learning o f their children es pecially regarding ad option o f hand

washing, which children ad opted after the school pr o gram. Previou sly the mothers had t o

scold them t o wash hands. T he mothers interviewed d uring FGD in Rawlak ote were ad opters

while the mother interviewed was a non-ad opter. She had not ad opted any behavior change.

Common themes

1. Adoption of new behavior

2.

Sharing of new behavior 3. Pride of Learning and material possession

4. Motivation for Change: health benefits, Islamic teaching, Saving of medical cost

Objective 5: To Build the Capacity of Partners to Implement the Community Hygiene

Promotion Program/Involvement of Key Channels in Promoting Improved Hygiene

BehaviorsUnder this objective Partner NGOs (grantees) were trained who in turn trained and oriented :

y women volunteersy Mosque Imams

y Physicians

y Operators of Filtration plant

y Local NGOs & CBOs

y and approached:

y Local retailers

PSDW-HPP trained local volunteers in Interactive theater and partner NGOs arranged

y interactive theater session in communities


objective: SSI / 4 Project Coordinators, SSI / 4 Women Volunteer, SSI / 4 Mosque Imams,

SSI / 2 Doctors, FGD / 27 mothers, IDI / 4 mothers, FGD / 20 fathers, IDI / 4 fathers, Spot

visit/ 2 retailers (Okara/Gujrat), FGD / 13 Theater Volunteers, Questionnaire, Interview / 3

Consultants = 87

Data analysis: The training was adequate for HPs but not for PCs, according to PCs. Theattitude, knowledge and delivery of the HPs was admired by target audienc e and keychannels. All the channels were effective except doctors, ACCORDING TO PCs and HPs.

None of the 31 mothers met during research had visited/received a doctor/certificate. Womenvolunteers, mosque Imams, melas, theater performances were effective channels.

The mela and theater performances did not catch the imagination of the public in Rawlakote



The shop keepers did not know whether the dangler had been a cause for people to remember to buy soap but they admitted that it was an attractive dangler.

T here should have been a se parate training f or PCs with pr oject/ o ffice management mod ules.

L HW instead o f d oct ors would have been a more effective channel f or message and

certificate distribution as they visit community hou sehold as part o f their mainstream work.

T hey could have delivered the messages and delivered the certificates t o µbest ad opter

mothers¶. Also , the Health de partment at pr ovincial level could have absorbed the CHP-

woman vol unteers orientation design in the pr ovincial training instit utes f or L HWs at the

Federal/Pr ovincial level. T his would su stain the excellent resource design/material pr od uced

by the pr oject.

T he pr oject should have identified the popular l ocal events that mothers (and fathers) fr om Rawlak ote could attend.

T he IRC or PSDW-HPP should have ex plained the ob jective o f devising 8 scri pts f or different

target audiences o f the pr oject t o the CHP-NGOs and T heater vol unteers.

T he method f or boiling water f or 5 minutes and u sing clear bottles f or S olar filtration needs

reinf orcement. T this is so becau se a few mothers re ported this time incorrectly, however they

were corrected by others mothers. Also questions were asked about correct way o f S olar

filtration in Okara, Gujrat, S ukk ur and Rawlak ote by both mothers/fathers.

T he theater vol unteers also re ported that the community asks them questions about S olar

filtration and also terms it un-islamic. T his notion needs t o be removed.

T he attraction o f getting a free soa p did attract the community t o melas in Okara, Gujrat and S ukk ur but not in Rawlak ote.

Common Themes

1. Innovation, uniqueness of training design

2.

Separate training for PCs on project/office management3. Adoption of NGO manual in mainstream work of Grantee Partner / CBO

4. Excellence of support material

5. Motivation for Change: health benefits, Islamic teaching, Saving of medical

cost

6. PPP embarrassing for NGOs

Objective 6: Community Hygiene Program Implemented in Targeted Districts

NGO Hygiene Promoters (HP) conduct:y fathers¶ support sessions

y mothers¶ support sessions

y Interactive theater

y Hygiene melas

W l t t i i & f ll



The following Tool / Sources for Cross Reference/ Triangulation were applied to assess theobjective: SSI 4 CHP project coordinators, FGDs 24 HPs, FGD 13 Theater volunteers, SSI 4

Women volunteers, SSI 2 doctors, SSI 4 mosque Imams = 51

Data analysis: Program design was deemed unique focusing on involving and engaging the

community through interactive activities. Another success was the development of attention-

grabbing and illustrative BCC material i.e. calendars, posters, danglers, flip charts, desktop

reminders etc. Project¶s BCC material was appreciated by all. Grantee NGOs¶ scope of work

was also meticulously designed and they were provided with support by the project through

quarterly mentoring visits. However both the PCs and HPs lamented the lack of technical

knowledge regarding water purification methods under the project .

Theater performances/Melas were effective channel in Okara, Gujrat and Sukkur. This is notso for women in Ralakote who do not attend melas/theaters. In the opinion of the local HPsonly school functions are occasions which women attend or they go to tombs of historical

religious leaders on their death anniversaries in Rawlakote.

Melas are an effective channel to disseminate the message to a large audience.

Doctors did not prove to be an effective channel.

Mosque Imams were a very effective channel as they adopted the work of the project as part

of their own duty as the messages corresponded to Islamic teachings.

Community mentioned the distance to filtration plant as a hindrance. Frequent power outagesare also a hindrance.

T he technical questions o f the community/stakeholders are genuine. T he print media in

Pakistan d oes cover the chemical attributes o f plastic, arsenic content o f boiled water reg ularly thr ou gh articles. T he community is not unaware and should not be considered

sim ple by devel opment pr o fessionals. T hese as pects should have been covered in the ca pacity

building o f NGOs/ key channels.

T he u se o f 8 scri pts f or different target audience should have been made clear t o NGOs/ theater vol unteers.

P opular l ocal events f or Rawlak ote should have been identified in collaboration with l ocal

teams.

L HW would have been a more effective channel as they visit community as part o f their mainstream work and could have distributed the certificates t o µbest mother¶ upon observed

confirmation o f required changed behavior in mothers.

Very few pr ojects engage mo sque Imams, and that also effectively, theref ore, when PSDW-

HPP engaged them, they felt privileged. F urthermore, mo sque Imams deem, and rightly so , pr oject¶s messages are in line with the teachings o f Islam regarding hygiene.T he mo sque

Imams were the mo st effective channel.

Pr ovision o f a ppr opriate infrastr uct ure is a prerequisite o f a behavior change pr o gram. T hecommunity request t o install filtration plant at union council level is genuine. T he PSDW-

HPP may consider taking this up f or advocacy with g overnment authorities.



6. Appreciation of use of Islamic teachings in project material

Objective 7: Improved Hygiene Behaviors at the Household Level

1. Improved hand washing behaviors, Hand washing with soap at multiple critical

times (self and teaching children to do so), Air drying of hands

2. Hand washing stations set up at the household level (two places), HW station set upnear kitchen, HW station set up near latrine, Provision of soap at both locations


objective: FGD 27 mothers, IDI 4 mothers, FGD 20 fathers, IDI 4 fathers, SSI 4 women

volunteers, SSI 4 mosque Imams = 63

Data Analysis: All the respondents reported adoption of improved hand washing behaviors i.e.

hand washing with soap at multiple critical times (self and teaching children to do so) and air

drying of hands. The team observed 1 house per district during FGD with mothers. 1 house

per district during IDIs with mothers. 3 houses were observed during IDIs with fathers in

Okara, Gujrat and Rawlakote. 3 households were observed during SSI with womanvolunteers. This brings the total to 13 houses observed under CHP field work. Two hand

washing stations with soap were observed in all the houses near/in kitchen and outside latrine.All the respondents reported that use of soap has increased as previously they use to think

that washing hands with soap was enough. Rubbing hands with soap for 20 seconds and notusing towel is the behavior change they have adopted.

63 respondents interviewed had reportedly adopted improved hand washing behaviors.

12 hou seholds had made the change t o having 2 hand washing stations after their ex po sure

t o pr oject activities.

Common theme1. Behavior change adopted for the sake of family¶s health2. Increase in usage of soap

3. Increase in hand washing stations

Objective 8: Improved Hygiene and Safe drinking water Behaviors at the Household

Level

1. Adoption of at least one water purification method, Households obtain water from

filtration plant, Households appropriately purify water by boiling, Solar filtration

2. Improved water storage at the household level, Drinking water kept in clean, raised,

covered containers, Water taken out of container through tap, long-handled scoop, or

poured from a narrow-necked container

The following Tool / Sources for Cross Reference/ Triangulation were applied to assess thebj ti FGD 27 th IDI 4 th FGD 20 f th IDI 4 f th SSI 4



The respondents had adopted one water purification method. The 14 mothers in Gujrat saidthey use to boil water before mother¶s session but had switched to Solar filtration as it was

easy. The 7 and 6 mothers in Sukkur and Rawlakote respectively were using both methods

interchangeably. If they had time they boiled water, otherwise they use solar filtration. Water filtration plant was only used if it was near or en route to male members daily routine. The 4

mothers, 4 women volunteers and 4 mosque Imams elaborated the barriers to boiling water as

it is time consuming and the community cannot afford boiling water. Solar filtration is cost

free and less time consuming. Water storage at household level was observed in 13 houses.

This was kept in coolers / fridge in Okara, Gujrat and Sukkur as it was early summer. The

water was observed in plastic bottles in houses in Rawlakote. However the 6 mothers during

FGD also reported the use of pitcher in Rawlakote.

S olar filtration methods should be reinf orced as it being popular, carelessness and f orgetf ulness in behavior is an ex pectation that cannot be r uled out .

Common themes

1. Filtration Plant being used only if it is near or en route to male members daily routine

2. Solar filtration is easy3. Boiling water is costly and time consuming

4. Water storage is as per project¶s message

Objective 9: Develop radio spots for airing and use other Mass Media approaches insupport of program activities

y Design and implementation of effect of air radio and other mass media approaches


objective: IDI 4 mothers, IDI 4 fathers = 8

Data Analysis: Only one mother in Gujrat had heard the radio spots by PSDW-HPP. She

liked the Punjabi language used in the radio spot. She also liked the mother-daughter

dialogue used in the spot to convey the message.

It is by chance that the team could not meet any res pondent who was a radio bu ff.



6. BEHAVIORAL IMPACT FROM INTEGRATED BCC APPROACHThe overall approach in the PSDW-HPP was to work directly with NGOs, while providing

support through local staff and consultants. The process was carried out in a series of stages.

Supporting materials for both hygiene promoters and the target audience were prepared whilethe promoters received appropriate training. As the PSDW-HPP is nearing/has completed

some of it¶s major program activities, it commissioned a case study research. The

methodology to produce the case study comprised determining and defining the research

questions for data collection to be gathered through participatory research tools i.e. focused

group discussions (FGD), in-depth Interviews (IDI) and semi-structured interviews (SSI).

The questions were formulated, submitted and finalized in English-Urdu between the period

March 09-21, 2009. After a pilot in Okara-Punjab on April 2-3, 2009, the questions, research

study methodology and Informed Consent Form were submitted to International ResearchBoard (IRB)-Washington. Following formal approval from IRB on April 16, 2009 the field

work was undertaken as follows: Gujrat-Punjab, April 19-24, 2009, Sukker-Sindh, April 27-

May 02, 2009 and Rawalakote-Azad Jammu Kashmir, May 03-08, 2009. The following table

shows the application of research questions per target audience and key channels:

Community Hygiene Promotion

Target Audience & Key Channels Okara Gujrat Sukkur Rwalakote Total

FGD Mother 0 14 7 6 27

IDI Mother 1 1 1 1 4IDI Father 1 1 1 1 4

FGD Father 0 6 8 6 20

SSI Woman Volunteer 1 1 1 1 4

SSI Mosque Imam 1 1 1 1 4

SSI Doctor 1 0 1 0 2

FGD Theater Volunteers 1 4 4 4 13

SSI Project Coordinator 1 1 1 1 4

FGD Hygiene Promoters 2 6 10 6 24

School Hygiene Promotion

IDI with female teacher 1 1 1 1 4

FGD with mothers of students 1 6 8 4 19

FGD with female students 0 5 8 6 3 19

IDI with male teacher 1 1 1 1 4

FGD with male students 8 8 4 20

IDI with mothers of students 1 1 1 1 4

SSI with representative of education

department

0 0 1 1 2

FGD with Hygiene Promoters 1 5 6 4 16

The outcome of the public-private partnership and media campaign were collected throughthe above FGDs, IDSs and SSI with NGO staff/community during the relevant session. Theresearch questions focus, probe and analysis is as per following table. These were repeated

for each target audience (TA) and key channels (KC) for triangulation of findings:

Question Focus Probe Analysis



whether TA and KC found the

activity adequate different for Project Coordinators who

recommend training with project/office

management modules in addition to generic

BC training. Retention The emphasis was to ascertain

whether TA and KC remembered the

key messages of the activity

The TA/KC retained the messages.

Adoption The emphasis was to ascertain the

adoption of key messages learntduring activity

The TA/KC were practicing key behaviors.

(Next Table)

Behavior Change

(BC) The emphasis was to ascertain what

was the previous personal practice of

the TA and KC

Rubbing hands with soap for 20 seconds, air

drying and solar filtration were never

practiced before. Motivation for BC

The emphasis was to ascertain why

the TA & KC chose to change the

previous practice

New learning, which is logical to keep safe

from germs and practice hygiene

Barriers to BC The emphasis was to ascertain the

barriers they encountered/observed to

behavior change

Boiling water is time consuming and costly

Facilitators to BC The emphasis was to ascertain the

facilitators encountered/observed to

behavior change

Cost of soap is less than medical cost.

Solar filtration is easy.

Anything is easy, if done for own children.

following tables gives an analysis of adoption against the key behavior that the project was

promoting:



Behavior Change Analysis of adoption

y Hand washing with soap for 20

seconds at multiple critical times

(self and teaching children to doso)

y Air drying of hands

y Hand washing stations set up

near kitchen/ near latrine with provision of soap

These key behaviors were adopted because they were

innovative. Hand washing stations were set up because it is easy

to remember to wash hands, if you see soap. Soap near/in

kitchen is facilitating factor for mothers.

Adoption of one water purification

method

y Households obtain water from

filtration planty or boil/use solar filtration to

purify water

Solar filtration is adopted because it is easy and cost free.

Boiling water is time consuming and costly. Filtration plant is

used if it is near or en route on male members daily routine.

y Drinking water kept in clean,

raised, covered containers

y Water taken out of container

through tap, long-handled scoop,

or poured from a narrow-necked

container

The use of log handled scoop is a new learning for Rawlakote

and has been adopted. It was mentioned by the community.

Keeping a pitcher for water storage was also mentioned in

Rawlakote only. The weather in Rawlakote was still chilly. In

Okara, Gujrat and Sukkur, as it was early summer, use of bottles

in fridge or keeping water in cooler had started. The community

in Punjab/Sindh only remembered to mention long handled

scoop, when prompted. This response may have been differentin winters.

5.1. Major findings

5.1.1. Community Hygiene PromotionThe PSDW-HPP promoted hand washing with soap at multiple critical times (self and

teaching children to do so), air drying of hands. The corresponding facilitator was hand

washing stations set up at the household level at two places; near kitchen and near latrine

with provision of soap at both locations. It also promoted adoption of at least one water

purification method i.e. boiling for 5 minutes, Solar filtration or households obtain water

from filtration plant. It promoted improved water storage at the household level with drinking

water kept in clean, raised, covered containers and water taken out of container through tap,

long-handled scoop, or poured from a narrow-necked container. The target audience under

CHP are: mothers and fathers. The key channels are: NGO Hygiene Promoters, theater

volunteers, woman volunteers, mosque Imams and doctors. This includes trained staff of

local NGOs and CBOs. The following table illustrates the adoption, facilitators and barriers

for the key messages of the project.

Target Audience Hand washing Water

purification

Water storage Facilitator

Mothers Adopted Adopted Adopted

Barrier/s for Soap is expensive. Difficult to boil Boiled water kept Projects messages



Barrier/s for

Fathers

Lack of

infrastructure i.e.

bathrooms in

Rawlakote

No barriers except

distance to plant4.

No barriers5 The adoption

reduced cost of

medicine

The BCC Objectives were clear to the target audience and key channels. All reported that the

objective of the intervention was prevention of diarrhea through good hygiene behaviors.

Protection of germs was also mentioned as an objective of the intervention. Interviewees also

mentioned protection of children under 5 as an objective.

The 31 mothers interviewed through FGDs or IDIs were appreciative, clear about objective

and had adopted hand washing with soap at critical times, one method of purifying water and

safe practices of water storage and retrieval. Their motivation was the protection of children/family from disease. All the mothers, except in Okara, mentioned the distance of the

water filtration plant as a hindrance in access to this safe water.

The 24 fathers interviewed through FGDs or IDIs were appreciative, clear about objectiveand had adopted hand washing with soap at critical times, one method of purifying water and

safe practices of water storage and retrieval. Their motivation was the protection of children/family from disease. The fathers in Okara and Punjab were using their ID card

holder whereas, the other 2, in Sukkur and Rawalkote did not remember receiving it. All thefathers, except in Okara and Gujrat, mentioned the distance of the water filtration plant as a

hindrance in access to safe water.

The 24 Hygiene Promoters interviewed were appreciative of their training. Duration of

training was deemed short. Another suggestion was that real community should have been

used for role-play during training. Also technical/scientific knowledge of the staff should

have been improved as they could not answer such questions of the community: why plastic

bottles get cracked in the sun, is this water safe?

The four (4) project coordinators interviewed including Okara, except Rawlakote, mentioned

that their should have been a separate training for them comprising project and office

management modules, before the implementation of the program. Three out of four CHP-PCs

also mentioned increase in technical knowledge for such question: boiling water increases

arsenic content of water. The four (4) project coordinators were appreciative of mentoringhelp from the project. However, the team found that there was only one mentoring visit to

Sukkur through the duration of the project. Nonetheless, the partner deemed it useful.

The four (4) women volunteers were appreciative, clear about objective and had adoptedhand washing with soap at critical times, one method of purifying water and safe practices of

water storage and retrieval. They knew that they were critical in bringing about change intheir community. They appreciated the material and follow-up of the project. The material

was a proud possession



purifying water and safe practices of water storage and retrieval. They knew that they werecritical in bringing about change in their community.

The mela was identified as a effective channel by both 28 partners staff and 17 key channels.The mosque Imams and doctors were not asked this question. The community in Punjab-

Sindh describes it¶s experience of a mela enthusiastically. They remembered the messages,

the theater performance, the gifts given and other activities of the mela. This enthusiasm of

the community could not be determined in Rawlakote. Only one father mentioned attending a

µHealth Seminar¶. He remembered that his children enjoyed the magicians trick. The mothers

met during the field work had not attended the mela in Rawlakote.

The four (4) mosque Imam were appreciative, clear about objective and had adopted handwashing with soap at critical times, one method of purifying water and safe practices of water

storage and retrieval. They knew that they were critical in bringing about change in their

community.

The team could meet only two doctors, in Okara during pilot, and in Sukkur. Both the doctorswere clear about the objectives of the partnership. The doctors mentioned that women are

happy when they receive the certificate of µbest mother¶. However, none of the 31 mothersmet mentioned going to the doctor or receiving certificate in any location.

The capacity of 23 channels (women volunteers, mosque Imams, doctors and theater

volunteers was built appropriately, and in the opinion of the 24 HPs and 4 PCs, WomenVolunteer and Mosque Imams are the most effective channels. Former because of their easy

access to and influence over mothers of children under five and the latter because very few

projects engage mosque Imams, therefore, when PSDW-HPP engaged them, they felt

privileged. Furthermore, mosque Imams deem, and rightly so, that project¶s messages are in

line with the teachings of Islam regarding hygiene. As reported by 24 HPs and 4 PCs, doctors

proved to be the least effective channel because majority of doctors engaged by the grantee NGOs are busy in their practice and hardly find time to promote project¶s messages amongst

mothers. However, it is pertinent to mention that, exceptions were reported under the

project¶s regular reporting formats.

Hand washing practices: Respondents washed hands at critical times for 20 seconds. Some

respondents mentioned time as µ20 minutes¶ but in the opinion of the team, saying ¶20

seconds¶ is a tongue twister, whereas 20 minutes comes to the tongue more easily. Hands

were air dried and this was also mentioned as the innovation, new learning by therespondents.

Hand washing places: Two places for hand washing were observed/mentioned by all

respondents/team. The community did not mention a barrier to the adoption of this behavior but the high cost of soap was mentioned by all respondents. Lack of infrastructure



Solar filter water in cloudy weather from Rawlakote. The facility of water filtration plant was being used by the community, if it was near to their abode.

M aintenance and u se o f water st orage containers. Appropriate behaviors were observed inthe maintenance of water containers and in the way in which water was drawn from the

containers.

Key channels to promote the above messages have made changes in personal behaviors

regarding the above. They also are committed to the health goal of the project. Doct ors were

identified as a weak channel by the NGO staff and other key channels. It is also pertinent to

mention that no mother from the respondents mentioned the receipt of certificate from the

doctor. The hygiene promoters could also not arrange for a meeting with such a mother butthey did mention that they meet mothers, who mention that the Project¶s messages were

given by the doctor.

Obstacles: One of the most significant obstacles to a more hygienic behavior was the poor

economic situation of the families/key channels (excluding doctors). It was difficult for themto afford material (gas, fuel wood) for boiling, adequate water boiling/storage containers and

other items, such as soap.

The following table gives an analysis of similar findings:

Similar

Findings

Recall Objectiv

e

Adequa

cy

Retentio

n

Adoptio

n

Behavio

r

Change

(BC)

Motivati

on for

BC

Barriers

to BC

Facilitat

ors to

BC

31

Mother� Health � � � More

conscien

tious

aboutcorrect

way of

H/W

and air

drying

New

learning

to

improveour

health

Boiling

water is

time

consuming and

costly

Health

gain/

SODIS

24

Father� Safe

from

diarrhea

/ germs

= health

� � � More

conscien

tious

about

correctway of H/W

and air

drying

New

learning

to

improve

our health

Distance

to

filtration

plant

Health

gain and

medicin

e/doctor

feesaving

4

Woman� Health � � � More

conscien

New

learning

Boiling

water is

SODIS



about

correct

way of

H/W

and air drying

improve

our

health

ns teaching

2 Doctor � Provide

healththrough

doctors

� � � N/A New

learningto

improve

our

health

Commu

nity areunaware

and lazy

Raise

awareness

13

Theater

Voluntee

rs

� Give

health

message

to

commun

ity thru

theater

� � � More

conscien

tious

about

correct

way of

H/W

and air

drying

New

learning

to

improve

our

health

Boiling

water is

time

consumi

ng and

costly

Humoro

us

/enjoyab

le

scripts

to give

message

4 Project

Coordin

ator

� Local

NGO

Separate

training

on

project/

office

manage

ment

� � More

conscien

tious

about

correct

way of

H/W

and air

drying

New

learning

to

improve

our

health

Commu

nity

beliefs

Excellen

t generic

BC

training,

selectio

n of

effective

channels

24

Hygiene

Promote

rs

� Provide

skills for

commun

ity work

� � � More

conscien

tious

aboutcorrect

way of

H/W

and air

drying

New

learning

to

improveour

health

Boiling

water is

time

consuming and

costly;

Commu

nity

beliefs

Local

commun

ity

channels/

Excellen

t generic

BC

training

5.1.2. School Hygiene Promotion

The SHP promoted uptake of doable actions by students through delivery of school

curriculum by teachers.

The SHP component was determined to be weak in Rawlakote. The female teacher reportedthat she could not do the experiments effectively due to the one room school which had no

other facility except student benches. The male teacher delivered the messages as a lectureand did not do any activity/experiment because he also reported that a one-room school and



of pitcher with a glass. Unilever gifts had not been distributed in the boys school visited. Thereasons identified for these weakness were that the education department did not send

relevant teachers for the training. This was discovered during follow-up by HPs. Also, onset

of long holidays in December and closure of school till March effected the proper follow-upand distribution of gifts. Follow-up of more than 2-3 schools per day in a mountainous region

is not possible. It was an unrealistic target for a 6 month project.

The actions and findings are as follows:

# Action Findings

1 Hand washing with soap before eating The respondents were practicing

2 Hand washing with after toilet The respondents were practicing

3 Air drying of hands The respondents were practicing

4 Hand washing with of younger siblings¶ hands and

air drying

The respondents were practicing

5 Take soap and water to mothers prior to meals This was not mentioned as a convincing behavior but the respondents did mention that

they helped mothers

6 Ask parents to buy soap The respondents do ask for soap from parents

7 Assist mothers with solar heating of water The respondents were practicing if mother was

solar heating. Where the mother was boiling,

the respondents did not help

8 Taking home calendar to mother The calendar is serving it¶s purpose and is a

proud possession of/for the whole family

Target Audience Hand washing Water purification Water storage Facilitator

Barrier/s for mothers Soap is expensive.

Children play with

soap

Difficult to boil andSolar filter for large

families

Plastic bottles get

cracked in the sun.

Water filtration plant

distant

Boiled water keptfor cooling can be

a cause of accident

in small

households

Projectsmessages are

good for health

of all

The 19/20 fe/male students questioned under SHP were not asked the objective of their syllabus directly but all seemed to be clear that cleanliness of hands is important and

necessary to protect from germs. They are practicing and promoting hand washing in siblings,however, their assertion that they help mother in hand washing did not seem convincing.

They were very appreciative of the syllabus.

The 4/4 fe/male teachers were appreciative of the training. In Okara, Gujrat and Sukkur, the

teachers had conscientiously delivered the school curriculum, but this was not the case in

R l k Th h d b i / h h l i R l k



soap in school bag in the children. The team met only one non-adopter mother under the SHPcomponent in Rawlakote. Her decision to not change stems from the belief that old practices

are time-tested.

Key channels: the key channels for this component were hygiene promoters/master trainers

and teachers. Both 16 hygiene promoters and 8 teachers had adopted the key messages of the

project. However non-availability of appropriate infrastructure within schools was

mentioned/observed. These included lack of toilets, running water within schools. In

Rawlakote lack of initiative for both appropriate conduct of experiments/activities for the

curriculum and sustainability of the effort was observed.

The following table gives an analysis of similar findings:

TA/KC Recall Objecti

ve

Adequa

cy

Retenti

on

Adoptio

n

Behavio

r

Change

(BC)

Motivat

ion for

BC

Barrier

s to BC

Facilita

tors to

BC

4

female

teacher

� Train

children

/commu

nitythroughteachers

� � � More

conscien

tious

aboutcorrectway of

H/W

and air

drying

New

learning

Boiling

water is

time

consuming andcostly

Commu

nity

beliefs

SODIS

22

mothers

of

student

s

� Teach

children� � � More

conscien

tious

about

correctway of

H/W

and air

drying

New

learning

Boiling

water is

time

consumi

ng andcostly

Commu

nity

beliefs

SODIS

19female

student

s

� Keepsafe

from

germs

� � � Moreconscien

tious

about

correct

way of H/W

and air

drying

Newlearning

NA NA

4 male

teacher� Train

children

/commu

� � � More

conscien

tious

New

learning

Boiling

water is

time

SODIS



germs about

correct

way of

H/W

and air drying

1 non

adopter

mother

of

student

� Not

Applica ble

(NA)

X � X NA NA Previous

Practice

NA

16

Hygiene

Promot

ers

� Provide

skills for

school

work

� � � More

conscien

tious

aboutcorrect

way of

H/W

and air

drying

New

learning

Boiling

water is

time

consuming and

costly

Commu

nity

beliefs

SODIS

5.1.3. Public Private Partnership

Major findings regarding the public private partnership were negative as detailed by 24 HPs,

4 PCs (CHP), 2 teachers and 16 S-HPs interviewed. The only positive aspect reported by

them was that as it was a µfreebie¶, it caught the imagination of public. Only 1 PC and teacher

mentioned the positive aspects of the germ glow machines. The 2 other teachers did not

mention it¶s importance and impact but said that it was a µgood game for children¶.

All of the community respondents (fe/male students and mothers) reported the receipt of soap,

as a positive gift. The students had adopted the habit of keeping soap in their bags after

receipt of the gift and the mother corroborated this behavior.

The major findings were as follows:

y There were a lot of delays in the shipment of material and the partners had to devote

time and effort for follow-up with Unilever to receive their material in time for a

particular activity. This resulted in wastage of time and extra work for partners. It is

pertinent to mention that SHP was a six month project component.

y The germ glow machines did not specify µhandle with care¶ or µfragile¶ due to which

the courier company did not handle them with attention. Most did not work whentaken out of the packing box. These were fixed by partners on their own with PSDW-

HPP/ Unilever support. A lot of resources and time were thus wasted.

y The PSDW-HPP had been very strict about not promoting names of soap and insisted

with the partners that they should promote the message that any soap can kill germs if the suds are produced for 20 seconds. The posters sent had the following message in



y It is known to Pakistani public that original red life buoy soap does not produce suds.It also uses a color due to which hands and water become red. By using the red life

buoy to promote use of soap in the community, the PSDW-HPP contradicted another

important message that suds kill germs. The PSDW-HPP should have guided theUnilever to send quality soaps which produce suds. This low quality soap also created

problems for the partners.

y Germ glow machine demonstration was considered a farce by the community. ThePC-SHP were given an orientation after the memorandum of understanding was

signed with Unilever by PSDW-HPP. During the orientation a different germ glow

machine was used for demonstration than the one sent to the partners. Machines were

not working when they arrived in the field due to the fact that the courier company

was not instructed to µhandle with care¶ and/or µfragile¶ cargo. The NGO had toemploy an electrician to make the machines work. The germ glow machines were low

quality and usually the teacher¶s reaction was that µaidee wi pagal banan di lore nahin¶

[don¶t think we are so stupid.] Most science teachers knew that fluorescent powder

shines and they embarrassed the team during the demonstration. Unilever trainingguided that it would take 40 minutes to show a demonstration but it took 1 ½ hour in

each school.

y During the orientation the partners were informed and given written instruction about

the 11th

activity to be conducted with the partner schools, in addition to the 10

activities contained in the curriculum. This 11th activity was translated and shared

with the teachers. It specified that good hygiene practicing students will be gifted with

badges, bandanas and lunch/pencil boxes. The preceding items never arrived under

the partnership. Children were only given soap and pencil box. Also the pencil box

was of low quality. The teachers who knew about this 11 th activity got angry with the

SHP staff saying that HPs have pocketed the money of the other gifts or have kept the

items with them and given them low quality things only. This created image and

reputation problems for the partner.

y The partners were not informed about the distribution criterion at the time of theorientation. When they received the material under the component, they wereinformed that the material should be distributed as per the following criterion: piped

water, wash basin and boundary wall available in the school. The criterion was not

based on items which were the responsibility of partners and/or PSDW-HPP¶s own

focus. The question is: what about the children of a school where there is no boundary

wall but the teacher/students have produced excellent results? The teacher/students

cannot be penalized for not meeting the above criterion. The criterion should have

been adoption of critical behaviors by students. The PSDW-HPP was not working for the provision of above mentioned criterion with the district government. This criterion

was not in the control of teachers-students who were the main target audience and key

channel.

y Wall charting was started by Unilever to promote life buoy during the same time asmaterial was received from them for distribution This created an erroneous



y The items for children¶s gifts were of low quality, especially bandanas. The bandanaswere made of cotton bands in the beginning but were later replaced by paper bands

stapled together. As the students would try to fix them on their heads, the staple/pin

holding the bandana would come off. The use of sharp material to make thingsintended for children is not recommended. Also the change in material created animage problem for HPs as the teacher thought they were corrupt and mishandling the

funds.

y As most schools have children from class 1-5 sitting together, gift distribution to some

children created complex situation for HPs as it was hard to explain to a child of class

3 why s/he could not be given a gift.

5.1.4. Mass MediaIt is by chance that the respondents met during the field survey had not heard the radio spots

produced by the project, being aired by local FM channels. Only one mother mentioned that

she had heard a radio spot once and had liked the content, style and language of presentation.

The shop keepers met during the field survey did not mention that they noticed whether any

consumer looked at the dangler and remembered to buy soap. However they did say that it is

an attractive dangler and consumers must look at it.



7. CONCLUSIONS AND RECOMMENDATIONS

The results of the research are encouraging in that they show positive changes in the number

of respondents practicing hygiene behaviors do appear to be related to the specific activitiesof the project. Major conclusions drawn from the respondents are:

y A decrease in diarrheal prevalence (six-month recall) occurred for children.

y An increase in hand washing of primary caregiver after defecation is reported

y An increase of hand washing of children after defecation and before the child ate isreported

y An increase in the presence of a permanent, designated hand washing location is

reportedy An increase in use of soap for hand washing is reported

y Improvements are also reported in hand washing technique for 20 seconds and air drying of hands.

The determination, dedication, and motivation of community hygiene promoters and theater

volunteers stood them in good stead. In addition, the tasks that they were being asked to dowere feasible and they were well accepted by the communities.

The hygiene promoters had attained a good understanding of the hygiene message and

content that they were responsible for communicating. They demonstrated extremely fine

interpersonal relationships and were obviously trusted and well-received by households.

However, the negotiating aspect of their counseling needed improvement in Rawlakote. The

team in Rawlakote exhibited a tendency to µdo¶ rather than negotiate and decide what should

be done before exploring the situation in greater depth with the households. This could

probably be because of pressure from the project.

6.1. Process Results

y NGOs / Coordinators / Hygiene promoters increased their skills in management of groups, behavior observation, Trials for Improved Behaviors¶ (TIPs), qualitative

analysis of obstacles, development of strategies to address obstacles, testing of strategies, preparation of materials, and organization of a community launching

activity. They also received practical training in behavior change communications

y The project was able to strengthen capacity for implementing Behavior Change asindividuals from districts all over Pakistan received training in the use of materials

and in implementing and planning hygiene behavior change programs. Some of these

organizations had been involved from the initiation period of the project. These main behavior change partner organizations are trained and can be called/used as trainers,



y Partners strengthened their inter-institutional links and ties. The ground has thus been prepared for institutionalizing a network of behavior change communications

promoters.

y The project was able to document a Hygiene Behavior Change Approach. Materialsused in the project were refined and produced and made available to a number of

organizations and are now being used in their programs.

y The project carried on activities outside the health/hygiene sector through trainingteachers and implementers to apply principles of behavior change in government

primary schools through creating a special curriculum for use in the schools. This

resulted in implementation of the Behavior Change Strategy in Schools.

6.2. Hygiene results

y The desired hygiene effect from behavior-change interventions is a reduction indiarrhea prevalence. During the survey respondents were asked about diarrhea

prevalence within the past six months for all children. All of the respondents reporteddecrease in diarrhea incidence. While this decrease may be attributable to the program

interventions, it could possibly also reflect seasonal variation as the case studyresearch was conducted right after the winter season in Pakistan.

6.3. Behavior change results

y The survey is suggestive of improvements in health and positive changes in behavior

² especially hand washing behaviors. These improvements should be viewed as

resulting from a well designed behavior change program.

y As a result of capacity-building training, and dissemination of materials, behavior

change approaches are being used in most provinces of Pakistan.

6.4. Recommendations

y The Lady Health Workers are identified as a key channel by NGO staff, consultantsand the community. It is argued that they could have improved the outreach of CHP

as they are better placed within the community.

y The criterion to distribute gifts through public private partnership, under the SHP

should have matched the program objectives. If the project was working for

availability of infrastructure under the school hygiene promotion, then it may have

had this criterion for distribution of gifts under the public-private partnership to



y The organizations /consultants that participated in training have developed inter-organizational/personal links, and the trained staff/consultants have formed ties

among themselves. These links and ties have created a nascent behavior change

communication network. This network needs to be made sustainable. A plan for making it so, is needed. The challenge for PSDW-HPP is how to build on what has

been achieved so that the enthusiasm and interest do not dissipate. Some coordinating

mechanism is needed. PSDW-HP is well qualified to play the role of coordinator for such an initiative and network.

y A website needs to be created and maintained so that electronic communication is

possible among trained behavior change consultants/staff and organizations.

y The training material of the project under CHP and SHP should be institutionalizedwith the government training institutes affiliated with the health and education

department in all provinces. This will guarantee its continued usage and application.



42

Self Reported / Observed Behavior

Community Hygiene Promotion Component

Target

Audience/

Key

Channels

Total Adoption of Hand washing with

soap at multiple critical times (self

and teaching children to do so)

Air drying of hands

Hand washing stations set up near

kitchen/ near latrine with provision

of soap

BC Adoption of one water

purification method

Households obtain water

from filtration plant

or boil/use solar

filtration to purify water

BC Adoption of Drinking water

kept in clean, raised, covered

containers

Water taken out of container

through tap, long-handled

scoop, or poured from a

narrow-necked container

BC

Mother 27 100 % Self reported 100 % Self reported 100 % Self reported

Mother 4 100 % Self reported& Observed

100 % Self reported& Observed

100 % Self reported&Observed

Father 4 100 % Self reported

& Observed 100 % Self reported


Observed

Father 20 100 % Self reported 100 % Self reported 100 % Self reported Woman

Volunteer

4 100 % Self reported



Observed

Mosque

Imam

4 100 % Self reported 100 % Self reported 100 % Self reported

Doctor 2 100 % Self reported 100 % Self reported 100 % Self reported Theater

Volunteers


Project

Coordinator


Hygiene

Promoters




43

School Hygiene Promotion Component

Target

Audience/

Key

Channels

Total Adoption of HW w/soap:

before eating

after toilet

help family wash hands and air

drying

BC Adoption of Take soap

and water to mothers

prior to meals

Assist mothers with solar

heating of water

BC Adoption of Ask parents to

buy soap

Taking home calendar to

mother

BC

IDI with

female

teacher

4 100 % Self reported NA6

but purify and store

water as per message Self reported NA Self reported

FGD withmothers of

students

19 94.7 % Self reported 94.7 % Self reported 94.7 % Self reported

FGD with

female

students


IDI with

male

teacher

4 100 % Self reported NA purify and store water

as per message Self reported NA Self reported

FGD with

malestudents


IDI with

students of

mother

4 100 % Self reported

& Observed

two H/W

stations

100 % Self reported 100 % Self reported

Calendar

Observed

SSI with

representati

ve of

education

department

2 NA N/A N/A N/A NA N/A

FGD with

Hygiene

Promoters

16 100 % Self reported NA purify and store water

as per message NA 100 % NA

6 Not Applicable as the question was not askxed from this particular respondent.

behviour change

Documents