Use of mass media, interpersonal communication and other forms of social marketing to build culture of hand washing

Proposal submitted by Racheal Natumanya. International Youth Empowerment Network (YEN)

Project Summary This project aims at instilling the culture of hand washing among children as early as one year when they start understanding so that the habit grows in them as they grow older. This project through promotion of hand washing will contribute to better early child development by cutting off the constant ingestion of faecal matter by children under 5 years. It is often difficult for grown-up adult mothers and other caretakers to take up the behavior of hand washing at critical times such as after using the toilet, before feeding children and after cleaning up children’s faeces, etc. The project will encourage caretakers in central Uganda to actively train their infants and young children to always keep their hands clean by washing them with water and detergents or other acceptable cleansing agents at critical times. When children learn early in life and develop the necessary skills, hand washing is more likely to become a habit they will practice for the rest of their lives. Most children develop the ability to wash their hands independently by about three years of age. Before that caretakers need to help them wash their hands (or for babies and young toddlers, caretakers need to do it for them). After age three, children will probably still need a bit of help. Teaching children about hand washing early in life is important. Hand washing prevents the spread of diseases which make children sick. Children are ready to learn about hand washing when they are still very young.

The project will use mass media, interpersonal communication and other forms of social marketing in which people will be reached with messages and the hand washing skills. The project will apply implementation research to identify the perceptions and opinions of parents and caretakers have towards—early child development, ingestion of faecal matter by children, training children on hand washing from early stages of life, perceived role models to achieve this, potential threats to the campaign and partners to work with to roll it out. The target for the project are parents with children below 5 years, teachers at schools, community leaders, older siblings, children 1 to 5 years, etc. Since infants and young children are copycats they are more likely to learn from others who are seen washing hands and would act as role models in the adoption of the hand washing skills in the long run.

Children do not always take time to wash their hands and often resist parents and caretakers when they are asked to wash their hands before eating, after using the toilet, after touching animals or upon return from playing with their colleagues. Caretakers will almost certainly need to give them lots of encouragement and reminders. Children do not always enjoy washing their hands, partly because it means time out from more exciting things like playing. So the best strategy is to find ways to make hand washing part of the fun, rather than a distraction from their favorite activities. To address this resistance, the project plans to apply fun filled and innovative approaches that are captivating to the children and are embedded into the usual activities they engage in.

To address the challenges around hand washing facilities, the project will identify and use partnerships with established organizations (CSOs, NGOs, FBOs and government) that are supporting provision of such facilities. The project will also integrate nutrition and stimulation of children within the hand washing intervention. Finally, in order to sustain the intervention, the project will work through government instituted National Sanitation Working Group (NSWG) and its National Handing Washing Steering Committee (NHWSC), ministries of education and health, district local governments, communities and private sector providing sanitation and hygiene services or goods as partners.

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Introduction Early child development (ECD) is a critical life event for all humans yet the recent global evidence indicate it is not receiving appropriate attention. ECD is a product of environmental, biological and social factors, which require addressing in an integral manner. This project is one of the first focused on promoting hand washing culture as means of reducing ingestion of dangerous pathogens by infants and young children. If successfully implemented at scale, the project will contribute to better ECD outcomes by addressing reducing ingestion of microbial pathogen that increase the risk of stunting and anaemia and their associated adverse effects on brain development. Using a two prolonged approach that focuses on children as the primary target and mothers/other caretakers as secondary audience, the project is overcoming the current WASH programmatic limitation of focusing on mainly mothers and caretakers. Children are the ones who are loaded with dangerous pathogens and are ingesting them during play or during feeding. Hence by focusing on them the project expects to reduce ingestion of the pathogens and to create a generation which takes hand washing as an acceptable behaviour.

BackgroundMotor skills—running, sitting and more complex movements, etc.; cognitive skills—thought, memory and logic; socio-emotional and development of language are part of the key development milestones that children attain as they transition from being a dependent infant to an independent teenager. Changes in child development occur as a result of interaction between biological factors—nutrition and environmental influences—parents-child relationships, community characteristics and cultural norms over time. Hence, interventions targeting environment, child or both can influence outcomes of child development. Such intervention should take into consideration that developmental outcomes in children are influenced by cumulative effect of biological, social and family risk factors and not just by individual type or weighting of each factor. The risk factors occur across different domains of influence—microsystem, mesosystem, exosystem and macrosystem (Figure 2). Higher levels of risk are related to poorer cognitive development, psychological distress and behaviour and communicative development and symbolic behaviour1.

Figure 1. Adaptation of Bronfenbrenner's ecological model for child development

1 Kariger et al. Examining Early Child Development in low income countries. A tool kit for assessing children in the first five years of life. World Bank Human Development Group. Washington, DC. April 3, 2009.

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These interactions work to form lifelong abilities for children during the pre-school age (Figure 2). Interventions to enhance cognitive and non-cognitive skills in children are more likely to have long term impact if the interventions occur early. Mothers and caretakers could therefore instill hand washing behaviours to children during this time so that they grow up into autonomous teens and adults who fully appreciate the value of hand washing and can eventually pass it on to their own children and neighbours. But we have to note cultures have a wide range of values for what skills and abilities children should develop and when they should be exhibited—abilities may emerge earlier if they are valued and encouraged in a specific culture. Parenting skills and ideas about child development are largely determined by cultural ideals. Consequently, program planners have to design interventions that are culturally appropriate to each setting and in consultation with caretakers and other community members. Educational home visits encourage better child care practices and increases mother-infant interactions probably through their effect on maternal depression2. Application of approaches that are community driven but catalyzed by external service providers are likely to better influence cultural practices for better early child development (ECD). Integrated approaches of household visits and education whereby village health workers, health assistants and community development officers go together to each community and provided ECD and nutrition related services would make a difference in Uganda. It would also make caretakers learn more, avoid receiving conflicting messages and save caretakers’ time by receiving both ECD and nutrition messages at once.

Figure 2. Timing of brain development

Of all the major risk factors that are threatening ECD requiring culturally appropriate and integrated approaches to overcome is environmental faecal contamination. Exposure of infants and young children to dirty playing and feeding is related to inadequate ECD outcomes (Figure 3).

2 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child. 2005; 90:1230–1234.[PubMed: 16159905]

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Figure 3. Summary of pathway linking poor hygiene in early childhood to child development (Adapted from Ngure et al. 2014).

Inadequate WASH practices are associated with 6.6 percent global burden of disease and disability, 2.4 million deaths due to diarrhoea and subsequent malnutrition and their consequences3. It seems WASH account for 50 percent child and maternal underweight4. WASH interventions if implemented with 99 percent coverage would reduce diarrhoeal disease incidence by 30 percent, which would in turn reduce the prevalence of stunting by 2.4 percent at 36 months5. Of all sanitation and hygiene interventions, hand washing is promising at least from series of randomized control trials conducted around the world. Hand washing has been reported to decrease incidence of diarrhoea by 32 percent with meaningful effects on motor and cognitive development in children.

Although hand washing is a proven behaviour for better child development, its uptake by Ugandan communities is very low. According to Uganda Demographic and Health Survey of 20116, 29 percent of households in Uganda have a place for washing hands after using the toilet. Only 27 percent of the households had both water and detergent, and another 27 percent had only water for washing hands. Hand washing with water and soap was practiced mostly in the regions of Kampala (41.7 percent), Central 1 (45.2 percent) and western (31.8 percent). Karamoja and westnile had only 20 percent of the households with hand washing facilities. Western (51.2 percent), east central (42.9 percent) and Kampala (30.2 percent) had highest proportion of household which washed hands with only water. Westnile (9.9 percent), Karamoja (10.1 percent) and Central 1 (17.6 percent) had the lowest proportion of households washing hands with water only. No statistics exist on the prevalence of hand washing by children under 5 years in Uganda but it could be speculated to be much lower than the currently reported statistics for adults.

The same survey showed the prevalence of diarrhoea in children under 5 years reduced from 26 percent to 23 percent. The prevalence of dysentery also reduced from 6 percent to 4 percent in the same year. Children of age 6-11 months (43 percent) and 12-23 months (37.6 percent) are more prone to diarrhoea than children of the older age group—24-59 months. Unlike in 2006 where there was significantly higher number of children with diarrhoea in rural areas than in urban, in 2011 rural children (24 percent) were only slightly

3 Pruss-ustun, A.B.R., F. Gore & J. Bartram. 2008. SaferWater Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health. Geneva: World Health Organization.4 World Bank. 2008. Environmental Health and Child Survival: Epidemiology, Economics, Experience. Washington, DC: World Bank.5 Bhutta, Z.A., T. Ahmed, R.E. Black, et al. 2008.What works? Interventions for maternal and child undernutrition and survival. Lancet 371: 417–440.6 UBOS & ICF International Inc. (2012). Uganda Demographic and Health Survey 2011. Calverton, Maryland, USA: Uganda Bureau of Statistics and ICF International Inc.

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more likely to have diarrhoea than urban children (22 percent). The statistics show the prevalence of diarrhoea varied with the region—children in east central (32 percent), eastern (33 percent) and Kampala (24.1 percent) and lowest in southwest (14 percent). Prevalence of diarrhoea reduced steadily with increase in wealth and was lowest in children whose mothers had at least secondary education (19.6 percent).

As result of poverty, environmental hazards, health care and maternal attributes, Uganda still has high prevalence of stunting (33 percent) and anaemia (49 percent) in children zero to five years6. From these statistics—hand washing, diarrhoea, stunting and anaemia one can conclude the vast majority of children in Uganda do not gain their ECD outcomes as expected.

Problem statement and justification for the projectDespite the role of diarrhoea in childhood malnutrition, current evidence points at environmental enteropathy to have more profound effect on early child development. Exposure to large quantities of faecal matter due to poor sanitation and hygiene practices causes environmental enteropathy that is responsible for stunting and anaemia that eventually impair ECD7. Human and animal feet are often contaminated with loads of faecal matter infected with dangerous microbes and pathogens which are deposited in children’s play and feeding environment. Such faecal matter end up in children’s mouths as they play and ingest soil matter. Whereas cutting this faecal to mouth route in children is difficult given the hyperactivity of children, training mothers and caretakers on hand washing with soap, safe food preparation, heating, cooling, and storage could reduce the risk of environmental enteropathy. This however is insufficient to overcome the challenge of ingestion of faecal matter by children as it is the children who are directly loaded with faecal matter. It is therefore important that in addition to mothers and other caretakers that WASH interventions directly focused on children for own hand washing at critical times.

Ngure et al. (2014)6 recommended adoption of new technologies especially child play areas as means of reducing ingestion of dangerous pathogens by children. This is scientifically appropriate but at the moment looks impractical socially, economically and culturally inappropriate in African setting. Yet it is also almost impossible to eliminate faecal matter in children’s play and feeding areas. Promotion of behaviour change interventions for hand washing by children and their caretakers in addition to traditional household WASH behaviour change together with targeted hand washing, hygienic preparation and storage of complementary foods for children seems the most viable approach to reducing ingestion of these pathogens by children. If the behaviour is instilled into children at an early stage of life, the children are more likely to grow into healthy and productive adults with a culture of washing their hands. A vicious cycle of hand washing could easily be created as result of such intervention if it is promoted at scale. Not only will this save lots of resources currently spent on enticing adults who did not grow up washing their hands, but will also create population of adults who grow to their full potential. In addition, it is important to explore the social, economic and cultural acceptability of the concept of safe child play spaces in low income households.

Obtaining perceptions and opinions of the mothers and other caretakers regarding child centred WASH interventions and on how to reduce environmental enteropathy and diarrhoea would be important in designing the hand washing intervention to reduce the interaction between faecal-oral vectors of the child’s hands and the hand-to-mouth activity.

7 Francis M. Ngure,Brianna M. Reid, Jean H. Humphrey,Mduduzi N. Mbuya, Gretel Pelto, and Rebecca J. Stoltzfus.WASH, environmental enteropathy, nutrition and ECD. Ann. N.Y. Acad. Sci. ISSN 0077-8923 pg.118-128

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Project GoalTo contribute to the improved early child development outcomes through reduction of morbidity and undernutrition among children below 5 years due to ingestion of faecal matter.

Objectives.1. Assess the perceptions and opinions of parents, grandmothers, teachers, health and community

service providers and other community representatives on hand washing and prevention of ingestion of faecal matter by children under 5 years in Central Uganda

2. To promote the culture of hand washing among children below 5 years using mass media, interpersonal communication and other forms of social marketing in Central Uganda

3. To establish and strengthen linkages and partnerships with existing government, NGO, CSO and community interventions to increase the accessibility of hand washing facilities within Central Uganda

4. To establish cost effectiveness and acceptability of hand washing among children and mothers/caretakers as form of protecting children against ingestion of dangerous microbial pathogens and associated adverse ECD outcomes in Central Uganda.

Project ActivitiesObjective 1: Assess the perceptions and opinions of parents, grandmothers, teachers, health and community service providers and other community representatives on hand washing and prevention of ingestion of faecal matter by children under 5 years in Central Uganda.

The key activities for this objectives are described:

• Design and conduct implementation research • Develop communication plan and creative brief to promote hand washing among children under

5 years in Central Uganda• Design, pre-test and finalize behavior change tools for children, schools and the parents to use

for promotion of hand washing among children under 5 years in Central Uganda. This activity includes identification of ideas that make the intervention fun for children, caretakers and teachers

• Pre-testing and finalization of behaviour communication messages for promotion of hand washing among children under 5 years in Central Uganda.

• Conduct district based meetings for review and finalization of the communication tools for the promotion of hand washing among children under 5 years

Objective 2: To promote the culture of hand washing among children below 5 years using mass media, interpersonal communication and other forms of social marketing in Central Uganda

The following are the main activities the project will undertake in order to achieve objective 2:

• Identify media houses to partner with in providing mass communication for the targeted audience in Central Uganda

• Signing of contracts and memorandum of understanding with media houses for the provision of mass communication for the targeted audience

• Provide logistical support to district and community hand washing champions to encourage adoption of hand washing among children under 5 years in Central Uganda

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• Identification and signing of memorandum of understanding and contracts with owners and operators of day care and kindergarten vans for airing of video testimonials and messages on the buses

• Organizing community action cycle within communities where parents and caretakers come together to identify challenges on environmental enteropathy, ingestion of faecal matter by children and how to promote behaviour change interventions to reduce ingestion of faecal matter by children

• Implementation of campaigns through radio magazines, spot messages, DJ mentions and talk shows

• Organize and hold workshops and trainings in schools and communities, to teach the children how to wash hands

• Installing the washing materials in schools and communities to facilitate hand washing both at home and school

• Training of groups of parents/caretakers and children through radio listenership program• Arrange exchange visits among parents and caretakers to other communities excelling in

promotion of hand washing among children• Organize community level sessions for rewarding children, teachers and parents exceling in the

campaign• Conduct periodic monitoring of the campaign in Central Uganda.

Objective 3: To establish and strengthen linkages and partnerships with existing government, NGO, CSO and community interventions to increase the accessibility of hand washing facilities within Central Uganda.

The following are the key activities that the project will implement under this objective:

• Conduct consultative meetings with National Sanitation Working Group (NSWG) and its National Handing Washing Steering Committee (NHWSC), Ministry of Education, Ministry of Water and Environment, media agencies, USAID, DFID, WHO, UNICEF and other development partners

• Conduct and write report rapid mapping of all agencies implementing WASH, nutrition and ECD related interventions in Central Uganda

• Hold consultative and planning meeting with relevant agencies implementing WASH, nutrition and ECD to plan for how to integrate hand washing into ongoing interventions

• Develop orientation package for integration of hand washing into ongoing WASH, nutrition and ECD related interventions in Central Uganda

• Orient technical representatives of agencies running WASH, nutrition and ECD related interventions in Central Uganda on promotion of hand washing among children under 5 years

• Monitor integration of hand washing into ongoing WASH, nutrition and ECD related interventions in Central Uganda

Objective 4: To establish cost effectiveness and acceptability of hand washing among children and mothers/caretakers as form of protecting children against ingestion of dangerous microbial pathogens and associated adverse ECD outcomes in Central Uganda.

The following are the main activities that the project will implement under this objective:

• Design protocol for conducting baseline, midterm and end of project evaluation of cost effectiveness and acceptability of hand washing among children under 5 and mothers/caretakers in central Uganda

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• Present the protocol to national and district stakeholders in central Uganda for approval • Conduct baseline, midterm and end of project evaluation of cost effectiveness and acceptability

of hand washing among children under 5 and mothers/caretakers in central Uganda• Disseminate baseline, midterm and end of project evaluation results of cost effectiveness and

acceptability of hand washing among children under 5 and mothers/caretakers in central Uganda

Sustaining the project intervention• The continued commitment of teachers is essential to the continuation of washing hands

encouragement and training of the children also for the parents to be committed in guiding and supervision of these children as the adopt to the behavior.

• As this behavior is targeting the children when they are young we hope that when they grow older they will teach their young fellows the same practice.

• Involvement of the private sector such as companies providing detergents is likely to keep the intervention on going even after the end of this project.

• By integrating the current proposed intervention into ongoing government, development partner, CSO, NGO and community WASH, nutrition and ECD intervention is also likely to enhance its sustainability.

• Reduced provision of handouts such as detergents and encouraging communities to purchase the items at subsidized rates or to make own items would enhance its sustainability.

Strategic information, monitoring and evaluationSince this intervention is new and is targeting relatively new environmental enteropathy, strategic information, monitoring and evaluation are key to its success. Data from the project will form collaborative learning and adaptation at all levels of implementation. The project Strategic Information, M&E team will design appropriate tools to facilitate accurate documentation, sharing of lessons and improvement in program implementation.

The following logical framework provides key indicators, activities, resources and assumptions for the project.

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Project Logical frameworkYEN-HAND WASHING PROJECT

OBJECTIVES

(What you want to achieve)

INDICATORS

(How to measure change)

MEANS OF VERIFICATION

(Where & how to get information)

ASSUMPTIONS

(What else to be aware of)

Goal:

Outcome 1

Outputs

1.11.2

Outcome 2

Outputs

2.12.2

2.3

Outcome 3

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YEN-HAND WASHING PROJECTOBJECTIVES

(What you want to achieve)

INDICATORS

(How to measure change)

MEANS OF VERIFICATION

(Where & how to get information)

ASSUMPTIONS

(What else to be aware of)

Outputs

3.1

3.2

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