Water and Sanitation Program: Technical PaPer 66001 The Power of Primary Schools to change and Sustain handwashing with Soap among children: the Cases of Vietnam and Peru Pennelope Dutton, Rocio Florez Peschiera and Nga Kim Nguyen September 2011 the Water and Sanitation Program is a multidonor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Acknowledgments: This document was written by Pennelope Dutton, World Bank’s Consultant, Rocio Florez Peschiera, Peru’s Handwashing Initiative Coordinator and Nga Kim Nguyen, Vietnam’s Handwashing Initiative Coordinator with contributions from Almud Weitz, WSP Regional Team Leader for East Asia and Glenn Pearce Oroz, WSP Regional Team Leader for Latin America and the Caribbean. It was peer reviewed by Eduardo Perez and Jacqueline Devine, both World Bank’s Senior Water and Sanitation Specialists. Layout: Shinny Montes First edition: September 2011 Print run: 500 copies Lima, Peru © 2011, World Bank’s Water and Sanitation Program www.wsp.org wsp@worldbank.org The results, interpretations and conclusions expressed in this document are responsibility of the authors and should not be attributed to World Bank, and the partner organizations, the members of the Council Meeting or the institutions they represent. Rights and permits The World Bank encourages the spread of its work and allows reproducing parts of this document, while the source is mentioned. Contents executive Summary .................................................................... 4 introduction ................................................................................ 6 i. Vietnam ............................................................................... 7 Background ......................................................................... 7 Handwashing with Soap Program, its History, Components and Partners ........................................................................ 8 research Findings ................................................................ 12 intervention .......................................................................... 14 Components and implementation ........................................ 16 integration and Scaling Up ................................................... 18 ii. Peru .................................................................................... 20 Background ......................................................................... 20 Handwashing with Soap Program, its History, Components and Partners ........................................................................ 21 Handwashing with Soap in Schools ..................................... 23 Formative research ............................................................. 23 intervention .......................................................................... 25 Components and implementation ........................................ 25 integration and Scaling Up ................................................... 29 Summary of Country approaches .............................................. 31 Lessons Learned ........................................................................ 32 Conclusion ................................................................................. 34 www.wsp.org 3 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Executive summary executive summary In Vietnam and Peru, handwashing initiatives within the siblings. Therefore, in Vietnam the program focus was on primary school setting, are increasing students’ handwashing handwashing with soap to prevent others from getting sick. with soap rates by using entertainment education approaches. In Peru, children in most areas were motivated to “help� their The initiatives were supported by the Water and Sanitation families to overcome certain burdens to come out of poverty. Program (WSP) through the Global Scaling Up Handwashing Children are therefore, motivated to influence their elders, Project. In Vietnam, the Women’s Union facilitated the to the program focused on their ability to became agents of training of 1,200 headmasters and teachers who carried change and some messages asked of them to remind their out handwashing activities in over 600 schools in 15 mothers to wash their hands with soap before cooking. Both provinces across the country. In total, over 340,000 students programs utilized fun and games with a superhero character were reached. In Peru, the Handwashing Initiative was that used soap to help others. However, the messaging and mainstreamed into the Ministry of Education’s system, mechanisms for relaying messages differed according to the through the Safe, Clean and Healthy Schools Program that results of the research. was implemented in 24 regions and trained 14,000 teachers who worked with 285,000 students. The fact that teachers needed incentives was also a key lesson. In Peru, teachers were overburdened with activities Although both countries based their program development and capacity-building sessions. Teachers needed to perceive a on a common framework under the Global Handwashing concrete benefit from additional commitments. Linking the Scaling Up Project, their implementation strategies were HWI program to performance indicators and recognizing markedly different. The need for formative research insights progress by means of certifications, proved to be effective that would help drive the design of the programs was a key because it translated in increases in teachers’ salary rates. In lesson from those programs. One relevant finding common to Vietnam, equipping teachers with a different approach to both countries was the fact that children already understood hygiene promotion and giving them simple tools that they the value of washing hands to combat germs. That was a could immediately integrate into their lessons proved to be platform used in building the programs. Research in Vietnam an invaluable incentive. revealed that children had very little free time and that teachers were already overburdened with a heavy curriculum. In both countries, a key aspect of the programs was the capacity Therefore, the entertainment education approach was used to to be a bridge between the school and the home and to link develop games and activities as extracurricular activities that children to the larger community. In Vietnam’s caretakers would complement rather than compete with the existing program, grandparents received messages on the importance curriculum. In Peru, the curriculum became the entry point of washing their own hands at key times. They also received for the program, particularly because the Education Ministry guidance on how to play games with their grandchildren to was ready to improve the national hygiene curriculum though help reinforce handwashing with soap messages delivered in policy development and regulations. schools. In both countries, mass media helped to link children to the larger community. In the case of Vietnam, it reinforced In both countries, the formative research sought to the school-based handwashing activities through national understand whether the children could act as agents of television programs, publications, and drawing contests. In change in their households and schools. In Vietnam, the Peru’s case, radio campaigns were supported by interpersonal ideal child was docile and submissive and unlikely to be able programs carried out in schools and elsewhere in each district to influence adults. Children could, however, influence their where the project was implemented. 4 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Executive summary Both case studies also offered suggestions on how to integrate handwashing with soap to increase its occurrence rate, by partnering with other actors in the water, sanitation and health sector or by mainstreaming handwashing with soap into education systems through policy, regulation and rewards. Regardless of the approach taken, both country case studies demonstrated that getting more children to wash their hands with soap was achievable. Project impact evaluation analyses in both countries are currently underway and the lessons provided in the present document are based on monitoring analysis of the behavioral change process in primary schools over the 2008 to 2010 period. Growing demand by national and local authorities to continue, scale up and further integrate approaches and tools developed by the project will lead to additional learning. These lessons should provide useful insights for governments, practitioners (including teachers and educators), NGOs and donors, who are interested in implementing a handwashing program in primary schools. www.wsp.org 5 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Introduction introduction Vietnam and Peru are two of four countries taking part in the and other hygiene behaviors, and they can initiate change, WSP Global Scaling up Handwashing Project.1 Funded by with teachers and other students acting as stable role models. the Bill and Melinda Gates Foundation, the Global Scaling Children are potential agents of change within their families Up Handwashing Project aims to expand handwashing and community. By sharing information from school with the practices among women of reproductive age (15-49 years) family, questioning existing practices at home, and influencing and primary school-aged children (5 to 12 in Peru; 6 to 10 the behavior of siblings in their care, children can change their in Vietnam) The Project focuses on applying innovative own behavior and that of others. Both Peru and Vietnam promotional approaches to generate widespread and have high primary school enrolment ratios.2 It was therefore sustained improvement in handwashing with soap practice. appropriate to focus efforts to increase handwashing with Started in December 2006, the project is implemented by soap by primary school-aged children on the primary school local and national governments with technical support from setting. Within this setting, efforts included learning about WSP, and participation from the private sector and non- and practicing handwashing with soap. governmental organizations. The case studies focused on primary school children, The Global Scaling Up Handwashing Project aims to show though they were one component of a wider handwashing which methods to stimulate and sustain behavior change at with soap implementation campaign. Both countries had scale work and have an impact on health. The purpose of already promoted handwashing for other target groups. this working paper is to share that knowledge, by presenting Complementary community programs targeting women— two case studies about changing the handwashing behavior often the mothers and caretakers of those same school of primary school children—in Vietnam and Peru. Although children—were implemented concurrently with the schools the programs operate in different country contexts, and use program. Direct consumer contact and mass media activities different approaches to achieve behavior change, the common and the interpersonal communication of the schools program and the unique experiences of these two countries provide were carried out simultaneously, and reinforced the change in lessons for others. Similarities include child-focused research knowledge, attitudes, and practices of primary school children. undertaken to understand the barriers to handwashing with WSP provided a common framework, a standard approach soap, the use of entertainment education, and the need and tools to assist the project implementation in both Peru and to build teachers’ skills and tools to effectively publicize Vietnam. One such tool was the framework called “FOAM� handwashing with soap. Differences are due to the social and (Focus, Opportunity, Ability, Motivation), developed by WSP geographical contexts of each country, the leadership role as a common conceptual framework for all four countries taken by government, the cultural differences of children as taking part in the Global Scaling Up Handwashing Project. agents of change, the degree of interaction between parents FOAM provided a way to analyze handwashing behaviors in and schools, and the education systems themselves. order to design effective handwashing programs. Childhood is acknowledged as the best time to adopt new The present document describes the approaches to behaviors. After the family, schools are potentially very changing children’s handwashing with soap behavior, first important places for learning new behaviors. Schools can in Vietnam, then Peru, followed by some lessons learned provide a stimulating environment to learn about handwashing and conclusions. 1 The two other countries participating in this initiative are Senegal and Tanzania. 2 Primary school enrolment ratios are 83% for Vietnam and 96% for Peru. 6 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam I. Vietnam Background Vietnam VietNam couNtRy Data Area: 331,210 km2 Population: 89.6 million (2010) Administrative regions: 58 provinces and 5 municipalities Children aged 0-14 years: 26.1% Under 5 mortality: 14 per 1000 (2008) Primary school enrolment: 93% Education expenditure: 5.3% GDP (2008) Source: CIA World Factbook, 2010 UNICEF Vietnam at a Glance www.wsp.org 7 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam country information Although personal hygiene was part of the school curricula, Vietnam has a highly centralized system of government physical barriers to handwashing with soap existed, including, in which the Communist Party plays a pivotal role in all in many cases, no designated areas for handwashing, aspects of politics, the economy and society. The country insufficient water and soap, and inadequate or broken toilet has some 54 ethnic minority groups, but the dominant facilities. Where handwashing and hygiene promotion had culture in Vietnam is that of the Kinh, which makes up 85 been included in water and sanitation programs, promotional percent of the population. The Kinh is a homogeneous social activities were usually not researched and developed to and ethnic group, whose language—Vietnamese—is the specifically target primary school children. official language of the country. Some regional variations of geography and climate exist between northern, central and handwashing with Soap Program, its southern Vietnam. Primary education is free and mandatory from age 6 to 11. history, components and Partners The Overall Program The importance of handwashing The Vietnam Handwashing Initiative (HWI) began in Acute respiratory infections are still the leading cause of January 2006 and aimed to reduce morbidity and mortality mortality and morbidity in children under five in Vietnam. from diarrheal diseases in children less than five years of age. Malnutrition is still high relative to other Asian countries, The HWI developed and implemented two communications with one third of Vietnamese children moderately or severely components; one for caretakers of children under five and one underweight, and children aged from 6 to 24 months at high for primary school children aged 6 to 10. The initiative was risk of malnutrition.3 The country has also suffered from supported by the Ministry of Health (MoH) and Ministry recurring outbreaks of Severe Acute Respiratory Syndrome, of Education and Training (MoET); the Vietnam Women’s Avian Flu, Cholera, and H1N1. These emerging diseases Union (VWU) was the main implementing partner. have increased the authorities’ awareness that improved hygiene was critical to preventing and containing serious The HWI was divided into two phases. The first (2008) outbreaks. involved piloting the HWI in 40 communes in eight provinces to change the behavior of mothers and caretakers. Baseline research showed that handwashing with soap Mass media campaigns and interpersonal communication was not a common practice in Vietnam. Soap products, delivered by trained motivators (primarily village health although readily available for most households, were used for workers, village leaders, teachers, and Vietnam Women’s handwashing only when hands appeared dirty or were smelly. Union members), targeted mothers to motivate them to A study conducted by WSP to understand the barriers and prioritize handwashing with soap, to help them understand motivations for handwashing with soap among caretakers in how best to manage soap and water and to improve their 2006 revealed that: understanding of both the health benefits of handwashing with soap and the critical times4 to practice it. The MoH • percent of caretakers washed their hands with soap before feeding a child; led in developing, training, and overseeing the interpersonal • percent of caretakers reported washing their hands at communication activities. critical junctures—but only with water; • percent of caretakers who washed their hands did not feel that soap was important or necessary. 3 http://www.wpro.who.int/vietnam/sites/dhp/nutrition/ 4 Before preparing food, before feeding children, after using the latrine and after cleaning a baby’s bottom. 8 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam Implementation of the component itself began in August Primary Implementation Partner: The Vietnam 2009 at the beginning of the school year, and it ended in May Women’s Union 2010. Since then, over 1,200 teachers from 600 schools in 15 The Vietnam Women’s Union (VWU) is a mass organization—one provinces throughout the country have carried out activities of several political and social institutions established by the government as a way to communicate down to the grassroots level involving over 340,000 students. about national government programs and initiatives. The VWU’s objective is to promote gender equity, foster the development of Formative research women, and protect the rights of Vietnamese women. It has more than 13 million members, and shares the same vertical structure The Global Handwashing Scaling Up Project encourages as a line ministry, operating at central, provincial, district, and the development of innovative effective approaches to commune levels. handwashing promotion. Unlike previous hygiene initiatives The VWU receives funding from the Government of Vietnam and external agencies such as UNICEF and the World Bank, as in Vietnam, the HWI undertook in-depth research of well as from its members. The presence and structure of mass children’s handwashing behavior in order to understand what organizations such as the WU in Vietnam gave the HWI a unique opportunity to reach millions of women and children with face-to- influenced their behavior and design appropriate campaigns face communications activities. based on the research findings. WSP commissioned an independent team of international and local consultants to carry out field research to learn The second phase (2008-2010) improved and scaled up the about lives of primary school children and the school and HWI, expanding it to target children of primary school age. home context where handwashing promotion will take place. The MoET participated in the development of the materials Gaining an insight into the minds and realities of primary and endorsed all print and media materials. Behavior change school children would help to better understand the barriers campaigns targeting mothers/caretakers and primary school and motivations to washing hands with soap. The research children followed a similar process of development: also sought to understand the larger context of the children’s world, including social dynamics, roles and responsibilities 1 Researching the audience; of teachers, a typical day in the life of a child (during the 2 Developing a behavior change framework to school term and holiday time), and their access to water, analyze research findings, guide the formation of sanitation and soap. the communication campaign and track changes in behavioral determinants throughout the life of the Aware of the difficulties of obtaining information from project; very young children, WSP focused the research on children 3 Developing the creative approach including messages from grades four and five (9-10 years old), although and tactics; younger children (grades 2-3) were included in one research 4 Pre-testing and adjusting the messages based on exercise. audience feedback; 5 Producing materials and rolling out of the activities; and Location Rural Peri-urban 6 Monitoring and making informed adjustments to the program. Northern Central handwashing with Soap in Schools Southern The development of the children’s component began with Types of schools participating in the formative research research in rural and peri-urban schools in July 2008. www.wsp.org 9 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam Six primary schools, chosen from three provinces to represent northern, central, and southern regions of Vietnam, took part in the formative research.5 Each province included one peri-urban and one rural school. Research tools included games and fun activities to encourage the children’s active participation and interest (See Box 1). A total of 30 students (boys and girls), divided into groups of about five students from each school, used each of the research tools, with the exception of the Motivator Pictures exercise—story telling based on pictures about handwashing—where younger children joined in. Eighteen students took part in the Belief Interviews that were followed up with observations of sanitation and handwashing facilities in their homes and interviews with their caretakers. Family structure diagram: the thick lines show the child’s strongest relationships and influences at home— in this case with mother (me) who is feared the most but who also buys them presents, followed by Formative research helped identify opportunities for after the grandmother (Bà), who the child likes the most. school points of contact with children. Studying the daily schedule, researchers were able to find out if children played together in the school yard after school, or whether there was an opportunity for contact at night through mass media. When children indicated they watched television, researchers prompted them for more information about what shows they watched and why. 5 WSP staff and local authorities chose schools that were representative of sanitation situations, were accessible and willing to participate in the research. 10 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam BOX 1: TOOLS FOR RESEARCHING CHILDREN’S HANDWASHING BEHAVIOR—VIETNAM Research tool Why was it used? How it was used? children’s research activities Role Models To understand who children look up to, why, and Children write down their favourite role models, what children want to be as adults. To integrate the reasons for their admiration, and the careers these characteristics into handwashing messages. they wanted. Pile sorting and voting were used to find group agreement. Track-the-Message To understand transmission of information between Teachers communicate a special message school and home, and explore the potential for about tooth-brushing to their Grade 5 students. schools to serve as agents of hygiene promotion in Students and their mothers are visited at their the community-at-large home the following day to see if the caretaker received the message, and if so, in what form. Daily Diary To understand how children spend their time in a As a group exercise, children fill in clocks to typical day. show how they spend their time each hour of the day. Daily diaries are developed for both school days and summer holidays. Motivator Picture To understand the emotional drivers for washing Various handwashing scenes are presented to hands such as disgust, morality, shame, regret. children and they are asked to tell a story based on how they interpret the pictures. Family Structure To understand the social relationships within the The child draws a diagram of their family child’s household, and the influences and constraints (showing themselves at the centre) and draws on handwashing. lines to the person in the home they are closest to, spend the most time with, and fear most. Belief Interview To understand children’s beliefs about handwashing; Individual student interviews on topics including to check if a ‘seeded’ message reached the child, the benefits to washing hands with soap, and the and in what form. causes of diarrhoea. School Hygiene To observe the use, quality, number and condition of Researchers complete a checklist on the Facilities Observation the school’s sanitation and hygiene facilities. numbers of toilets and urinals, taps, basins, staff and students (by gender), and presence of soap. School Staff Interview To understand the school’s organization, including In-depth interviews and focus group discussions teacher workloads, roles and responsibilities, and the with headmasters and teachers. connections between the school and home Caretaker Interview To understand primary caretakers’ economic Individual interviews of caretakers at home. concerns about handwashing, the support for handwashing at home, and whether the ‘seeded’ hygiene message reached family members Home Observation To understand access and availability of water and Direct observations of water, sanitation and soap at home. hygiene facilities in homes, using a checklist. www.wsp.org 11 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam research Findings and not seeing their friends wash their hands were all factors that limited children’s handwashing. Like Vietnamese adults, The larger School context children did not feel that washing hands was important or Rural Vietnam’s school setting presented unique challenges necessary unless their hands smelled or were clearly dirty. to effective promotion of handwashing with soap. The time when children were most likely to wash their hands in school The desire to prevent others, Children want to protect was after using the latrine, not before eating, as almost all especially their younger their younger brothers rural schoolchildren return home to eat their midday meal. siblings, from getting sick, and sisters from getting Only a few schools offer children the possibility of remaining sick. Regret at making motivated children to wash someone ill from not in school for lunch. their hands. Belonging to the cleaning dirty hands is the primary motivator Ho Chi Minh Young Pioneers for hand washing with Children wanted to go to school because of its friendly Organization was desirable soap. environment; they did not find rules strict and felt very safe because of its status and of there. However, the days were long and highly structured its interesting extracurricular with limited opportunities for play. activities. Children used television as a window to the wider society, and their role models reflect greater societal values, The school principal decided on school activities, and directed such as education, hard work and altruism. and supported teachers. Teachers had a full teaching load and no time to introduce new activities. Primary schools had to ability to influence Others at home strictly follow the curriculum issued by the MoET. Under At home, children’s voices were “small� (although it was pressure, teachers tended to focus on core subjects such “bigger� for boys). Parents had a high degree of control over as Vietnamese and mathematics and disregarded auxiliary their children; urban mothers had the most influence, and subjects such as physical exercise, the arts and personal rural fathers gave advice. The main role in teaching/educating hygiene. Handwashing with soap instruction was often only children belonged to the parent who spent the most time theoretical, as the lack of soap (and water and sanitation at home, but the father was the final decision maker in facilities) prevented children from washing their hands with educating children. Grandparents also had an important role soap at school. in children’s lives as they often played with them or looked after them while the parents worked. Older children felt Personal Barriers to and Motivations for handwashing protective towards their younger siblings and could guide with Soap their behavior. Children’s influence on caregivers was not Research showed that school children liked the smell of soap strong, especially in rural areas, as the image of a “model� and knew that they needed to wash their hands with soap. child is one who was docile and submissive. They understood the relationship between germs and disease and the role of washing hands with soap in protecting their Handwashing with soap was important because of its low health and preventing the spread of diseases like diarrhea, priority at home. Adults did not consider handwashing with bellyaches, and the flu. soap a priority and did little to encourage their children to wash their hands with soap or to reinforce the practice. Laziness, forgetfulness, lack of time or of desire to take time for washing, competing priorities such as playing football, 12 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam FOaM Framework and FOaM-eM for School Program In Vietnamese, “em� means “little brother or sister,� so FOAM- The WSP-developed FOAM framework for the Global 6 EM was a memorable acronym. FOAM-EM identified key factors Scaling Up Handwashing Project provided a way to analyze influencing primary school children’s handwashing behavior the determinants, or factors, that can improve or hinder and their relationships with family, school, and community. handwashing with soap behavior (access to soap, beliefs regarding the cause of diarrhea, social norms and product The objectives of the communication campaign emerged attributes, etc.). from the analysis of the findings from research using this FOAM-EM framework. In Vietnam, the FOAM framework was adapted to target primary school children. This variation, called FOAM-EM After the campaign, children in semi-urban and rural school (Focus on Ability, Opportunity, and Motivation—Ecological ages 6-10 will: Model), used the findings of an innovative research • Know that even clean-looking and clean-smelling study conducted in Vietnam with technical support by hands can carry germs; the London School of Hygiene and Tropical Medicine.7 • Believe that handwashing with water alone is not enough—soap is needed; FIGURE 1. FOAM - ECOLOGICAL MODEL SOCIETY SCHOOLS Pioneers Union FAMILY Values Parents Associations CHILD Social Social Access, Knowledge, Attitudes, Norms Support Products atributes Beliefs, Competing priorities Media Teachers Mothers Headmasters Fathers Classmates Grandmothers Siblings 6 FOAM was prepared for use by the four countries in the Global Scaling Up Handwashing Project. FOAM stands for: Focus: who are target audiences and what is the behavior we want them to adopt? Opportunity: is the target audience able to carry out the behavior? Ability: is the target audience capable of carrying out the behavior? Motivation: does the target audience want to carry out the behavior? 7 The true term is social ecological but EM is adopted for ease of use and relevancy. www.wsp.org 13 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam • Believe that handwashing with soap in front of friends The campaign used a fresh interactive approach by combining and family is an important to demonstration because school education, through games and songs, with national good handwashing will protect themselves, their mass media campaigns targeting children. Since television family and friends; represented Vietnamese children’s window on the outside • Be motivated to wash their hands with soap at two world, WSP supported an advertising agency in developing an critical times (before eating and after using the latrine); entertainment education program that combined mass media and and interpersonal communications to generate interest in and • Be motivated and feel excited about handwashing with enthusiasm for washing hands with soap and to promote that soap and want to practice it. practice. The program, which focused on colorful, attractive and positive characters, was developed around a superhero intervention who acquired special powers by handwashing with soap in order to help his family and others. The rural-schoolboy- Design turned-superhero story was broadcasted on several channels The handwashing with soap campaign for primary school identified as being important to children. Shows included children was developed directly from the key findings of the contests, television series on washing hands with soap along formative research. The campaign approach derived from the with school based activities. analysis of the findings’ implications. 14 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam FIGURE 2. RESEARCH-BASED CAMPAIGN DEVELOPMENT PROCESS Key findings Design Strategy Children have little • Few opportunities for Focus on times when children free time contact outside of school can be reached—during and at home school hours, and at night • Afterschool clubs, activities watching TV etc. are not offered Handwashing is already • Curriculum development Provide teachers with tools part of the curriculum but not required to highlight HWWS during teachers have a heavy • Handwashing should be environmental sanitation extra- teaching load easy to teach curricula activities, and make learning fun and interesting Television is children’s • Use of mass media is Place HWWS messages in window to the world appropriate channels targeting children • Popular children’s television e.g. “Goodnight Baby� TV shows and publications are show and “Youth� children’s an opportunity magazine Children’s key motivation • Develop messages that Position the HWWS campaign for HWWS is preventing emphasize the impact of with the child as “the pride of siblings from becoming ill the child’s behavior on the family� others, rather than him/ herself Children value altruism, • The campaign should Promote a superhero that, hard work and education emphasize the rewards by washing hands with of helping family and soap, acquires superpowers community to help his family and others in his village Grandmothers are cited • Utilize grandparent’s role Revised interpersonal as the person children as both caretakers but also communication materials they play with, most playmates to help reinforce to include guidelines for often handwashing with soap grandparents on how to play messages for children handwashing with soap games with children www.wsp.org 15 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam The notion of children as the pride of the family was the national Mass Media Materials and events platform upon which the children’s campaign was developed. The Bi concept and storyline were developed for use Handwashing with soap was positioned as an easy, fun and in national mass media activities. Nhi Dong (Youth) smart behavior with a tagline of “Wash your hands with soap magazine—a national weekly children’s magazine—printed for your own health and the health of others around you.� Bi cartoon strips in ten consecutive editions. Based on the Two different concepts for the superhero were pre-tested same story lines, the Bi cartoon strips were animated and aired and a final character, Bi, a rural schoolboy who becomes a on the national children’s television show “Goodnight Baby� superhero by washing his hands with soap to help his family every Saturday night for ten weeks. Handwashing content and others—was selected. The Bi character was refined and was included as well. The interpersonal communication pre-tested several times before final production. Promoting curriculum for schools, including the reproduction of the the two critical times for handwashing—before eating and cartoon strips in student booklets, was developed on the after using the toilet—and the six steps of good handwashing basis of these national media materials. practice were at the core of the campaign. These concepts were promoted in all school materials and media activities. Other national media events that attracted large participation were the national handwashing drawing contest (with 2,000 WSP supported the development of materials and training entries nationwide), promoted through Nhi Dong magazine, curriculums for teachers, and provided technical oversight in and Global Handwashing Day in which 1,000 schools in the development and implementation of all activities. 2008 and 2009 participated, and which obtained local and national media coverage. components and implementation The superhero Bi was the starting point for developing the media materials. The relationship between that concept and national media and materials used in schools for interpersonal communication is shown in Figure 2. FIGURE 3. RELATIONSHIP BETWEEN THE SUPERHERO CONCEPT AND PROMOTIONAL MEDIA Superhero Concept Bi the iconic superhero Bi appears in teaching materials, posters, stickers, comic strips and animated cartoons. Interpersonal National Media Communications Television show Student booklet Children’s magazine Posters & Stickers Drawing contest Teachers' guide and instructional DVD 16 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam Materials and resources for School-based activities The school materials used popular children’s games, School materials and teacher resources were developed as a set modified to promote handwashing in schools. They included of reference materials. WSP prepared the technical materials “Five Clean Fingers�, a song also used in the caretakers’ while the advertising agency helped to develop games and handwashing with soap campaign. Consistent images and visual materials for schools. Resources included: messages appeared throughout all materials, including • a teachers’ guide to carrying out activities such as stickers, and promotional items and materials developed games, songs and competitions, and information later. The Bi character was easily recognizable in all materials about handwashing such as the critical times for as the champion of handwashing. handwashing with soap, and the six steps • a “Wash your hands with soap for your own health Knowledge and Skills and the health of those around you� poster Program implementers and teachers in the pilot province • a CD with instructions for teachers on how to play and selected communes received training. Provincial level the games and implement the activities in existing representatives of the Women’s Union and the Department lessons of Education and Training followed a two-day training • wall paper—a blank poster of Bi and school friends course on how to impart knowledge about handwashing and which could be adapted for individual school use, such introduce the activities to promote handwashing in schools. as notices or games These master trainers then organized two-day training courses • a student booklet—a guide to games, key information for 2-3 representatives from every primary school in the target about handwashing, and 10 cartoons about Bi.8 area. About 30 school representatives in each course were Generally, 10 or 20 booklets were given to each introduced to the fundamentals of handwashing, the MoET- school—enough for one or two per class or a set for endorsed school materials and instructed on how to use them, the school library. and how to prepare a plan for follow up handwashing with soap promotional activities in school. Children washing hands with soap using a homemade HW station (note Primary school children learn about handwashing through fun and play. the sticker from Bi programme on the HW station). Here a group is playing “catch the dirty hand�, one of the games from the school materials. 8 These cartoons are the same as those printed in the national magazine. www.wsp.org 17 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam To overcome the schools’ lack of handwashing facilities, during the training courses teachers and principals learned how to develop low-cost handwashing stations. Rather than wait for large-scale investments to improve their water and sanitation facilities, teachers, headmasters or parents associations could purchase plastic buckets and plastic water dippers, which were inexpensive and available everywhere in Vietnam. Teachers are advised to put soap bars inside loosely woven fabrics so the soap remained inside a container at all times and could be more easily managed. After their training, teachers went back to their own schools and shared the ideas, experience and activities with other teachers. They then worked together to plan the implementation of handwashing with soap activities for the it makes a difference who attends the training. as well as the principal coming year. and Youth Union leader, Cho gao Primary School in tien giang province also sent the school nurse (L) to handwashing with soap training. now they work as a team to promote handwashing with soap in the school. implementation The Vietnam Women’s Union, with support from WSP, led according to the school nurse: the project implementation. The Women’s Union helped to “…Of course as a nurse I already knew about hygiene and the health organize the teacher training courses while WSP provided the aspects of washing hands with soap, but the training really helped materials for the training, the specialist trainer, and sets of to improve my communications skills. I now know how to convey school materials. The HWI also provided a list of activities messages to the children in a positive and interesting way. I didn’t know that could be included in a school implementation plan for this before...�. handwashing with soap, such as participation in the Global Handwashing Day; drawing contests; games; and wall paper demonstrations in their meetings. Other schools organized contests, with two optional activities of a skit and additional special days for the environment and handwashing with games about handwashing and hygiene. Schools received a soap that combined many games, competitions and small budget to help them carry out planned activities within demonstrations on handwashing with soap. Teachers adapted one school year. Each participating school carried out five the Teacher Resource Guide’s activity ideas to make skits extracurricular activities including entering the national and set up drawing contests, questions and answer quizzes, handwashing with soap drawing contest. and mystery word puzzles. In class, some teachers read the cartoons aloud, adapted traditional games or songs to Teachers found that the activities were very suitable for freshen the content of handwashing with soap instruction, primary school children as they were easy, fun and interesting or simply beat the school drum to remind children to wash to do. Using the materials to guide them, and their training, their hands. teachers introduced in schools many activities to promote handwashing with soap, often integrating them in novel ways. For example, handwashing with soap was introduced integration and Scaling Up into other subjects like citizen education, or included in routine school activities such as giving a talk or adding a Although the campaign component targeting school-aged game to Monday morning assembly. Some schools built children originated in seven provinces (where the mothers/ on the positive behavior examples of the Young Pioneers caretakers program was implemented), through integration Organization and included handwashing games and with other water supply and sanitation projects and World 18 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Vietnam the area of school hygiene promotion. The specialist skills Box 2: Hochiminh Young Pioneer Organization required to develop and deliver handwashing with soap in The Young Pioneer organization was founded by the Community schools was usually not readily available in typical water and Party and Ho Chi Minh under the Communist Youth Party. Children aged 9-14 can join and take part in school and community sanitation projects. By drawing on the HWI methodology, activities. It is an organization for talented and dedicated training program and materials, handwashing in schools Vietnamese youths patriotic who demonstrate solidarity, show discipline and good personal hygiene. Membership has status was given much higher priority and emphasis than would and leads into the Vietnam Youth Union for youths aged 15-30. otherwise have occurred. In primary schools, Young Pioneers have daily tasks such as checking the homework of other students, checking for clean hands and nails, and encouraging orderliness such as lining up. Boxes 3 and 4 give examples of direct implementation They make ideal peer-to-peer communicators and role models through the HWI and integration into a water and sanitation for handwashing with soap. program. Box 3: Direct implementation in Tien Giang province The VWU is implementing the HWI caretakers program and schools program in Tien Giang province. At the commune level, an Information, Education and Communications (IEC) committee, composed of four members: one from the Women’s Union, one from the local Health Centre, one from the People’s Committee (local government), and the principal of the local primary school, plans, coordinates and implements handwashing with soap awareness activities. The primary school principal works with teachers to organize and deliver handwashing with soap school activities, such as talks, games, quizzes, and demonstrations. The Women’s Union and other members of the IEC committee help coordinate planning, attend events, and lend their support. An effective example of this joint implementation is Global Handwashing Day. The Provincial Women’s Union advises and mentors some 90 IEC committees in the province to promote handwashing with soap, including in primary schools. Bank investment projects, the program has extended its coverage to 13 provinces—a much wider scale and audience than first expected. Box 4: Integrated implementation on the World Bank’s Red River Project Donors and NGOs were integrating the methodology The World Bank’s Red River Delta Water Supply and Sanitation and materials of HWI’s schools program for handwashing Project include a hygiene awareness component. In Thai Binh province, implementation of this component was contracted out with soap into their water supply and sanitation programs, to a local company, Infrastructure Thanh Long. The company including in major infrastructure projects. Several pilot had intended to develop a picture set to use when talking to schoolchildren about personal hygiene but did not have provinces for the National Target Program for Rural Water the resources or specialist staff to do formative research and Supply and Sanitation collaborated with WSP to promote prepare quality and effective materials for schools. Instead, the handwashing with soap in primary schools, including project in Thai Binh now uses the materials, methodology, and training developed by WSP, to support handwashing with soap through teacher training and support. in schools in 30 project communes. The project supports funding for implementation while WSP provides technical assistance. The company shares experiences and ideas between schools in the Historically, water and sanitation projects have paid little project and monitors the handwashing with soap program. attention to hygiene promotion, avoiding in particular www.wsp.org 19 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru II. Peru Background Peru PeRu couNtRy Data Area: 1,285,216 km2 Population: 29.9 million (2010) Administrative regions: 25 regions and Lima province Children aged 0-14 years: 29.1% Under 5 mortality: 24 per 1000 (2008) Education expenditure: 2.7% GDP (2008) Primary school enrolment: 96% Source: CIA World Factbook, 2009 UNICEF Peru at a Glance 20 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru country information handwashing with Soap Program, its Peru is a multi-ethnic, diverse society with a mixture of history, components and Partners cultural traditions. Although the main language is Spanish, Quechua and Aymara are spoken in the Andean region, and The history of the handwashing initiative (hWi) the Amazonian ethnic population speaks varied dialects. In 2003, a national multisectoral HWI was created in Peru Geographically, the country is divided into the arid plains to increase handwashing with soap among mothers and of the Pacific coast, the peaks of the Andes, and the tropical children of the poorest segments of the population. The jungle of the Amazon Basin. These geographical divisions early years of the HWI focused on laying groundwork, created environmental and cultural diversity, which, added to including a formative research study of households in 2004;10 a still deficient infrastructure network, made communication the creation of a consultative committee led by the Ministry efforts challenging. Peru is a highly decentralized society, of Health; and a national decree formalizing the HWI. The divided into 25 regions and the Callao (port in Lima) Ministries of Education, Health, Housing and Sanitation, constitutional province. Peru is also becoming an urban the National Program for Direct Support to the Poorest country with close to 72 percent of its population living in or Population (JUNTOS), regional and local governments, and around cities. According to the Constitution, initial, primary, private enterprise became involved in 2006 and have integrated and secondary education is free and mandatory in Peru. the HWI methodologies and tools into their programs. WSP has coordinated the HWI since its inception. The importance of handwashing In Peru, diarrhea is one of the main causes of disease and The HWI in Peru was implemented in two phases. The first death in children under five. Children typically have 5 to 10 (2005-2006) covered 14 regions. The Health Ministry headed episodes of diarrhea per year, each lasting up to four days. this phase and a ministerial resolution institutionalized the Children living in rural areas of the jungle and the Andes and HWI methodology. During this phase, health professionals, whose mothers have a low level of education are the most teachers and community promoters were trained on affected. Diarrhea aggravates infant malnutrition and remains communication for behavioral change, using a methodology one of the main causes of mortality from dehydration. developed to effectively target women and children. Despite the health education efforts coordinated between In the second phase (2007-2010), the program was redesigned the Education and Health Ministries, the country still to measure its impact on health and learn from the process. faced difficulties because segments of the population live in Covering 24 of the 25 regions, the HWI aimed to reach remote areas without access to basic services such as water, schools and communities in peri-urban and rural areas in sanitation and health. Health promoters and teachers in these the country’s three different geographic areas. areas were isolated and must commuted several hours once or twice a month to report on their progress, and did not The Overall Program have easy access to training and educational material. Even In Peru, the HWI’s “School and Community� project was though living conditions in poor urban settings were modest, implemented in 788 randomly selected districts in the 24 families’ access to public services9 was improving. Schools regions. Its objective was to stimulate and sustain change and health centers were closer to the neighborhoods, and the in the handwashing behavior of 1.3 million women and availability of potable water and sanitation was expanding. children. 9 Access to potable water in urban areas is 90 percent and access to sanitation is 81 percent, while in rural areas 61 percent of the population has access to water and 36 percent to sanitation. 10 Prisma, 2004, Behavioral Study of Handwashing with Soap in Peri-urban and Rural Areas of Peru. This study focused on handwashing with soap in the household, and some interviews with schoolchildren. It did not specifically nor systematically focus on primary school children’s knowledge attitude and practice. www.wsp.org 21 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru The approach was based on the assumption that sustained i Institutional development to ensure sustainability, hygiene-related behavioral change occurs when community including advocacy, partnership building, and capacity leaders and authorities endorse it, by when it is integrated into strengthening; health protocols and education curricula, and when its impact ii Planning and budget allocation done at national and on health is evident. Sustained behavior change is the result of local level with public, private and community based systematic and lasting multi-channel communication efforts organizations; that use a varied network of well-trained agents, interpersonal iii A communications campaign through local media and promotional events (street parades, local theaters, etc.) methods and direct consumer contact events and mass media. focused on the school and community; The following graph describes the components of the HWI iv Training of community actors and agents of change methodology. (such as teachers, medical professionals, community leaders), and provision of educational handwashing “School and Community� comprises several activities sessions for mothers and children. meant to achieve an integral and sustainable change at the community level. It targets women aged 14 to 49 and children aged five to 12, and engages multiple actors in the community over a period of time; these actors participate and become agents of change. The specific activities include: FIGURE 4. IMPACT OF HYGIENE PROMOTION PROGRAMS ON HEALTH IMPACT ON HEALTH Enabling Environment Agreements & Commintments Assesment Policies Research based program design Local Media Advocacy Campaigns Allocation of resources Hygiene Trained agents of change Practices Monitoring and Evaluation Social Partnership Mobilization Building Learning and scaling up Capacity Building Sustainability 22 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru handwashing with Soap in Schools and used HWI tools to reach and motivate children in the classroom. Safe, clean and healthy Schools The Ministry of Education and WSP designed a plan to integrate the methodologies and tools developed by the Formative research HWI into the recently-established Environmental Education Division of the Ministry of Education. The idea was to adapt With funding from the Bill and Melinda Gates Foundation, HWI’s “School and Community� approach to the Ministry in 2008 WSP conducted research on schoolchildren aged 5 to of Education’s “Social Mobilization: Safe, Clean and Healthy 12 to provide insights into their day-to-day reality, aspirations Schools� national program. This jointly developed component and attitudes towards hygiene. This research was necessary sought to promote handwashing with soap among primary to learn about children’s perception of their role as agents of school children by means of trained and motivated teachers change at school, home and the general community. Previous using tools and technologies developed to motivate children formative research in 2004 did not focus in detail on primary and their families to adopt good handwashing with soap school children. behavior. In that context, the child was considered an agent of change or a link with the family. He/she should bring home The formative research on children’s handwashing behavior new ideas to promote the behavior among the other family targeted six school settings, situated in urban and rural areas members. The main objective of the HWI methodology in the coast, the highlands and the rainforest. Several child- was to foster a change in schoolchildren’s behavior in hand- friendly and fun research exercises, such as drawings, were washing and general hygiene habits by promoting washing carried out in each school and activities also took place in the hands with soap before eating and after using the toilet. homes to understand the home situation and the interaction between mothers and their children (see Box 6). Research An operational plan was designed to reach 3,000 schools concentrated on the family; the child; cleanliness; the school; nationwide. By 2010, 12,000 teachers had been trained and handwashing practices. BOX 6: TOOLS FOR RESEARCHING CHILDREN’S HANDWASHING BEHAVIOR—PERU Research tool Why was it used? How was it used? home observations To understand the interactions between mothers Structured observation at children’s homes. and their children and handwashing practice at home. caretaker interviews To understand constraints to handwashing with In-depth interviews of caretakers at home after soap, caretakers’ attitudes and beliefs observation. Focus groups with To understand children’s aspirations, attitudes Focus group discussions with groups of girls and children and knowledge by age. boys from 5 to 7 years; two from 8 to 10 years and two of 11-12 years divided by sex. Focus groups with To understand caretakers’ attitudes, knowledge Focus group discussions with caretakers divided by caretakers and constraints to washing hands with soap. age: up to 35 years of age; and 35 years and above. School staff interviews To understand the school’s social environment In-depth interviews with teachers, the principal, and and management system. support personnel. School workshops To determine children’s motivations for Workshops for children in two classrooms by age. handwashing. Structured observations To understand the actual behaviour of children Observation linked to the motivational workshop. at school and their interaction with their peers. www.wsp.org 23 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru research Findings A key finding from the school research was that, together, mothers, children, and teachers formed a critical information pathway for conveying hygiene messages. Communication patterns differed according to geographical areas: horizontal and open in the coast and rainforest, and vertical in the Andean region. In the first case, children communicated information, offered opinions freely and received feedback. In this setting, children became agents of change. In the second case, children became messengers, channeling information from school that was valuable to the mothers. Even in this case, the role of the child was important, because mothers needed to be updated on the news and information that came from the teacher, one of the most influential and respected persons in the community. That finding supported the HWI’s motivation was their aspiration to protect their families from hypothesis that children were a key channel and potential poverty and disunity, and their willingness to take action. agents of change in the household. Children knew that they need to wash their hands even The character of the family had a strong influence on when they did not seem dirty, and were aware of the critical children. For example, in the Andean region communication times for handwashing and the need to use soap. However, within the family was vertical: children may bring relevant that knowledge did not always translate into practice. They information to their mothers, but they will not engage in forgot about handwashing especially if they were playing discussions about the benefits of handwashing. The opposite with school friends, and did not use soap because it was not was true among children in the coastal or Amazonian regions. available at school or at home. Water was not always available Usually children trusted their mothers the most, although for handwashing, as schools usually had water sporadically grandmothers were important, especially in rural areas. throughout the whole day. Children did not know about the Grandmothers played a role of confidants and caretakers of importance of using running water when washing hands and the smallest children. Brothers and sisters were frequently sometimes washing hands was more playing than washing. caretakers of smaller siblings, playing with them and teaching If toilets were saturated or dirty, children did not bother to them, while fathers were often absent and not expected to wash their hands after defecating. participate actively in their children’s lives. Teachers were admired (mainly by smaller children) or When asked about their future during focus group sessions, feared. Teachers thought it was difficult to inculcate habits children thought about being professionals (doctors, lawyers in children because of their home situation and tended or professors) in order to help other people (social motivation) to concentrate on theoretical aspects of handwashing and or, according to the youngest children, simply to help their hygiene. The level of priority given to handwashing was very own families. One relevant finding about children’s strongest dependent on individual teachers. 24 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru intervention Children benefitting from the program were expected to 1 Child motivation—working with those who motivate become agents of change among their peers, in their families handwashing practice in children, such as individuals, and the community where they live. The program aimed groups and families, and the public; to involve the family and the community in generating a 2 Ensuring water and soap availability in the area where culture of hygiene. children wash; 3 Applied knowledge, i.e. the child gets to know when The main contributions of the HWI to handwashing with they must wash their hands—after using the toilet and soap promotion in the school system were: before eating, and how they must wash. Training of Trainers • Methodology and manuals for teachers’ capacity building. The Ministry of Education delivered Trained teachers committed to spreading the methodology certificates that upgraded teachers’ performance and among fellow teachers at school. They either shared additional earnings as an official recognition of this capacity manuals and promotional materials or photocopy them. building; Trained teachers became advocates of hygiene and influenced • Promotional products and games to use in the school principals to allocate funds to fix bathrooms. classroom; • Development of a handwashing soap device called Social Mobilization within the School and in the Super Jaboncin. This highly appreciated plastic device community was used to set water and artisanal liquid soap by the Teachers were trained to develop an annual plan games school toilet. and activities to be carried out in the school during the year. Families were invited to join the organization and The Ministry of Education’s mainstreaming the handwashing participate in the event. As the program was linked to the with soap methodology gave the expansion of handwashing local government’s program, promotional events and parades with soap in primary schools across the country its biggest were frequently organized in the community with massive impetus. The health education component of the “Healthy, school participation. Safe and Clean Schools Program� uses handwashing with reporting and Monitoring soap as a key indicator and this is formalized through Teachers must report monthly to the district education unit Ministerial resolutions and national guidelines. The Ministry (UGEL, see below) on whether or not they are on track made the methodology and use of tools developed for with the plan. At the end of the reporting period, the UGEL handwashing promotion an official priority throughout the awarded the teacher and/or the school for performance and education system. The Ministry promoted application of results. the methodology, capacity-building and certification, and training in the participating schools. components and implementation capacity building Setting up the System The methodology to promote behavioral change was designed WSP spent time working with the central Ministry of based on research. It consists of a route that is followed by Education to prepare an operational plan for rolling out trained teachers to captivate and motivate the target audience the program on a wide scale. This meant identifying how to adopt the behavior. This route is sequential, logical and the program would be spread locally, and supporting the flexible and has three stages covering: process. www.wsp.org 25 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru The program implementation took into account Peru’s Local education units advertise participation in the HWI decentralized nature. At the national level the Ministry of program to schools, then support and motivate schools and Education formulates education policy, and at the regional teachers directly. They also monitor and certify the school’s level the education authorities have a management function participation in the program. and provide the budget and direction for education in their region. Below the regional level, local educational units Schools wishing to participate apply through their local (UGELs) have frequent direct contact and involvement with education unit. They commit to undertaking certain activities schools in their area. For example, teachers report to their in exchange for training and support. As well as handwashing local educational unit every month. It is this local education promotional activities in their own schools, they also must unit that is the critical link to implement the HWI. carry out some activities in the community, which they need to plan and coordinate with local municipalities. The community obligation aspect of the handwashing BOX 7: Participants in schools hand program component helps to build closer relationships between • Ministry of Education, through the Community and schools, communities, and local administration. It also Environmental Education Department normalizes handwashing at school and in the community. • The World Bank Water and Sanitation for Latin America Schools evaluate the program achievements and guarantee Program, through the Handwashing Initiative (HWI) an honest and transparent evaluation. • Regional education departments • Local education authorities (UGELs) • Elementary and primary schools BOX 8: Lessons from a teacher • School Environment Committee Mario Diaz Estela is a 44-year-old teacher at the Chontali • Teachers School No. 16107, in Jaen, Cajamarca Region. The school is one of six that has implemented awareness activities in • Students coordination with the Jaen UGEL, supervised by the Cajamarca Regional Education Department. “…It was very interesting to participate in the program and to help build people’s capacities for washing their hands with As evidence of the Ministry’s endorsement, assigned staff soap and running water. I was chosen to teach the trainers in several locations. travelled to each region to talk to regional education directors and local education units about the program and motivate Now I have a commitment to handwashing with soap and have taken on roles and responsibilities as a teacher. The training them to participate. Furthermore, they revised and validated has helped me improve learning in the educational community the behavioral change methodologies for handwashing; and I have been able to address thematic areas together with the health sector. I have also been able to strengthen personal developed guidelines for teachers’ certification; established and community hygiene habits. monitoring indicators, and developed policy at national and For students, there has been less diarrhea and chronic local level to uphold the program. The Community and malnutrition. Students’ learning capacity has improved and Environmental Education Department of the Ministry of they are organized now to cope with disease together�. Education issues regulations for the program and evaluates it nationwide. 26 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru Knowledge and Skills recent study in intervention areas, 70 percent of caregivers A cascading mechanism is used to provide the skills surveyed contributed to school campaigns by donating for bringing about behavior change in schools and the time, materials or money.11 Caregivers living in the jungle community. Four facilitating agencies were contracted and or the mountains of Peru tended to collaborate the most six regional coordinators recruited to support and oversee with schools, to promote better personal hygiene, not activities in the HWI program regions. People from these only by participating more in school activities but also by agencies and the regional coordinators received intensive contributing more to school-organized health campaigns. training from WSP to become expert facilitators and Almost 75 per cent of them sent soap to the school. Not only replicators. They trained master trainers, who, in turn trained was the program making schoolchildren agents of change at front-line workers such as teachers and health workers. home, but parents and caregivers were entering the school and joining in on handwashing with soap activities. Teachers received training that enabled them to share their knowledge with other teachers, hold educational sessions at incentives and rewards school, and organize social mobilization activities to involve The HWI utilized an important rewards and recognition the school in improving hygiene and creating a lasting system for schools and teachers. Not only did schools benefit culture. As part of the training, teachers received a manual from capacity building, support and materials, they also on the methodology to use in class. Following the training, obtained official recognition of their participation. If a school teachers returned to their schools and carried out educational actively promotes handwashing it may receive an award activities and mobilization to promote handwashing with from the Ministry of Education. As part of its monitoring soap. District-level education sector staff coordinated, tasks, the local education unit could validate the school’s organized and monitored the training events and school performance. activities. Teachers who participated in the training and applied handwashing with soap promotion successfully Teachers who had completed the training and show effective received a certificate from the Ministry. application were eligible for certification by the Ministry of Education. This certification recognized the improvement community and Parent engagement in teachers’ professional aptitude and lead to better jobs in The School Environment Committee is the key organization the educational system and higher earnings in the medium for planning and integrating handwashing with soap within term. Certification also served to reinforce teachers’ the the school. Composed of the school principal, teachers, a motivation and make behavior change more sustainable. The municipal councilor, members of the student council and local education unit provided a list of teachers for certification the parents’ association, the Committee prepares an action to the Ministry. plan, implements it, evaluates results and sends a report to the local education authority. regulations and local agreements National resolutions cemented the integration of the HWI Parents played an important role in the handwashing into the Ministry of Education’s “Safe, Clean and Healthy program. Parents’ associations are very strong in Peru and Schools Program�. Other Ministerial resolutions permitted they have a clear role on the School Environment Committee. civil society to participate in promoting the “Healthy, Safe Parents were asked to give soap to their children to bring to and Clean Schools� program, using the HWI behavior- school. The handwashing program demonstrably promoted changing methodology. closer relations between parents and schools. According to a 11 WSP, Impact Evaluation Baseline Survey in Peru, August 2010 www.wsp.org 27 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru In over 50 percent of the regions where the program was Schoolchildren identified with SJ through mass media (radio implemented, a regional or a local government agreement spots) and direct consumer contact events. These events already existed, or a regulation was being formulated to included fairs with many activities taking place at the same include the promotion of handwashing in schools as a time, including games for children, live theater, and kiosks priority. Schools in these regions designed handwashing where demonstrations and advice on where to place soap activities in the curriculum, using materials, awareness and how to set up a handwashing station could be shared raising and social mobilization. Children took an active part with mothers. Implementers were supplied with a kit that in recreational workshops where they were taught about the included an SJ superhero costume; three games with large benefits of washing their hands. props to engage audience participation; materials to give out to the audience such as posters and comic strips featuring complementary campaigns the SJ superhero; and a guide on how to use the kit materials Mass media campaigns, direct consumer contact and and conduct an event. interpersonal communication with mothers complemented the school education methodology. The communications This kit-based approach allowed for some standardization concept for mass media and direct consumer contact featured across regions and events, and ensured integration and a superhero named Super Jaboncin (SJ) (“Super Soapy�) who synergy with the mass media component. It also increased gained the power to fight germs by adding soap to water. the likelihood that teams delivering the events stayed “on message.� Regional coordinators, facilitating agencies, and partners monitored these events. Superhero Super Jaboncin (Super Soapy) fights germs with soap. many live theater events with Super Soapy, in primary schools, were made. 28 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru Solving the Soap Problem Schools with the handwashing device invited mothers Although parents were asked to give soap to their child’s to come to the schools to learn how to make the device. school, they did not always do so. Sometimes, soap was Children and mothers made an active contribution with stolen. The remedy for some schools was to put soap in a suggestions for the dispenser and how to care for it. Health mesh bag attached to the tap so that it was always available officers undertaking routine household visits checking on and used carefully. family nutrition followed up on the device—its use and durability. A recent study of 3,600 households found that A private company, DURAPLAST, designed a dispenser for in the households where there was a place for handwashing water and liquid household soap to promote handwashing with soap, there were 17 percent fewer worms in the children’s at school and at home. The idea for the dispenser originated stools.12 Evaluation of the device in schools has yet to be from mothers’ feedback about the need for a water dispenser carried out. to make washing hands convenient. WSP developed the idea to mix water and liquid soap in a dispenser, which it then trialed for six months in homes and schools in three integration and Scaling Up regions. Following some minor modifications, WSP funded the initial manufacture of the device, and later the Ministry Integration between health and education staff was evident at of Women and other organizations funded extra production. the local level. The “Health Promotion in Schools� Program WSP prepared an accompanying 3-step chart about the (Healthy Schools) of the Ministry of Health has been in effect device—what the device is, where to put it, how to use it, as since 2003 and has supported handwashing as a priority well as how long it will last. issue. At the national level, the Ministry of Health was only marginally involved with the Ministry of Education’s “Safe, Clean and Healthy Schools� Program, but health personnel in the field were active and visited schools and assisted with the planning and implementation of activities. HWI in schools was integrated into complementary programs by: • the National Program for Rural Basic Sanitation (PRONASAR), run by the Ministry of Housing, Construction and Sanitation. The HWI is part of a Joint Plan of Action for promoting handwashing in the intervention pilot areas, which includes investing in schools; • the JUNTOS Program and CRECER strategy, which consists of multi-sector programs coordinated by the Prime Minister’s Office with the aim of reducing the rate of chronic malnutrition. Handwashing with soap is included as an important action towards reducing malnutrition. a handwashing device helps to ensure soap is always available in school. 12 IMASEN, Baseline Study of Handwashing, Peru, 2009 www.wsp.org 29 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Peru • regional and local governments. The HWI methodo- logy has become an integral part of regional policies in five regions, which implies additional funding for hygiene promotion processes. • The Ministry of Women and Social Development that has adapted and integrated the HWI approach, me- thodology and tools into two of its national programs: Wawa Wasi and PRONAA. Wawa Wasi is the national nursery program that provides, care, stimulation and nutrition to children up to four years. The HWI has strengthened the reach to the child’s home, providing an added value that enhances results. PRONAA is a large national program that works with commu- nities, households and schools in 1,880 districts of the country to decrease malnutrition by educating and promoting nutrition and healthy habits. It also provides feeding in schools and community-based organizations. With the integration of handwashing with soap in the school education program, and active support from local education departments, more than 3,000 schools in 24 regions have taken part and as many as 300,000 students have benefited by the program. To date, around 15,000 teachers have been trained in handwashing promotion. In just three years, this is a remarkable achievement. During 2010, major public and private partners joined the action to promote handwashing in Peru, including the Ministry of Women. Also, agricultural (north) and mining companies (south) were funding capacity-building workshops for change agents, and the purchase of soap dispensers to be placed at schools and homes. 30 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Summary of Country Approaches Summary of Country approaches Vietnam and Peru’s approaches to school handwashing programs were different. The following table summarizes each country program: criteria Vietnam Peru Main target audience Schoolchildren aged 6-10 Schoolchildren aged 5-12 implementation level Provincial National Service delivery Vietnam Women’s Union, Ministry of Education, Ministry of Women and Social model provincial education departments Development; Regional and local governments; mining, agriculture, plastic, private firms role of private/non Professional services provided under contract Support for local schools government sector Funding for training activities Funding for HW soap device Monitoring process research methods Child-friendly research activities for students; Games with children; home visits; interviews and focus teacher interviews; home visits; school sanitation groups with teachers and mothers inspection communication Integrated entertainment education comprising Entertainment education integrating games and activities games, songs and other activities in schools, activities in school, street theatre, radio programs and national drawing competition, TV cartoons, soap operas, parades and promotional events newspapers Protagonist for Bi, a schoolboy who gets special powers by Super Jaboncin (“Super Soapy�), who gains the power handwashing handwashing with soap in order to help his family to fight germs by adding soap to water and others Main messages “Wash your hands with soap for your own health “The soap gives you power, don’t forget you must and the health of others around you� wash with it� “Share the power of soap, tell your mom to use it for HW before cooking� integration Examples of training, methodology, materials, or Capacity-building methodology and tools, as well as coordination integrated into: HW soap device integrated into: 1 Water and sanitation projects 1 A national guide for teachers in environmental 2 Provincial education department education (Ministry of Education) 3 National Target Program for Rural Water and 2 National nutrition programs (Ministry of Women and Sanitation Social Dev.) 4 Women’s Union IEC committees 3 Regional nutrition policies Sustainability/ 1 Provincial Education Department includes 1 National Budget includes funding HWI within the carrying it forward handwashing with soap training in budget. Nutrition Program 2 Provincial Governments investment programs 2 Regional Governments investments projects include HWI in schools include HWI 3 Private firms implement HWI in 2011 (after project ending) reach 15 of 64 provinces 24 of 25 regions www.wsp.org 31 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Lessons Learned Lessons Learned Both country case studies on handwashing with soap for engage in discussions or freely express an opinion. On the primary school children provided important lessons for other hand, they correct their siblings and remind them to future work in Vietnam and Peru. This section provides handwash with soap. This occurs also in the Andean regions insights that may be useful for other countries that wish to of Peru, where communication between parents and children implement effective handwashing with soap campaigns for is quite vertical. A total opposite is true of the coastal and primary school children at any scale. Amazonian regions in this country, where children take action and are talkative, and therefore become agents of change. Child-appropriate formative research tools reveal insights for effective programs Capacity building is critical The research methods and tools WSP used to investigate Skills-based training for teachers and education staff on schoolchildren were produced to elicit the critical information how to communicate handwashing with soap in schools needed to develop campaigns that would resonate with using child-friendly communications skills has triggered children and provide insight into their personal hygiene greater attention and priority to handwashing in schools. In behaviors, knowledge and aspirations. This evidence-based Vietnam, teachers appreciated having this new set of skills. approach avoids making assumptions about what motivates Practical training included site visits to selected schools children and what prevents them from washing their hands; so teachers could see realistic situations and good models it shapes the direction and style of the behavior change for handwashing with soap. In Peru, teacher training and campaigns targeted to children. capacity building were institutionalized through national capacity-building policy and a certification system for Focus on fun teachers. Certification provides financial and status incentives School handwashing with soap materials with contents that for teachers and helps build sustainability for handwashing focus on fun and not just education or health benefits are with soap through the continued commitment of teachers. easier for teachers to use and more interesting for children. Many programs focus on the effect of handwashing with soap Link schools with home and the community on the individual’s health, but both Vietnamese and Peruvian Schools are not islands. There are opportunities for children already understood the need to wash hands and the interaction between family and the broader community to relationship between germs and disease. The main problem support and reinforce programs for change in handwashing was that they often forgot or did not bother to wash hands. with soap behavior initiated in schools. For example, in Fun ways to overcome the barriers to handwashing—the Vietnam and Peru grandparents were part of the program belief that handwashing with soap is not important, the because grandparents (especially grandmothers) spent a lot lack of peer and adult role models, and the lack of water of time caring for children and mothers were not always the and soap—are more effective at producing lasting behavior most significant adult influence at home. In Peru, the HWI change than those focused on health alone. had very strong links to the local government programs and community events. Parents were encouraged to enter the Children as agents of change school environment to learn about handwashing. Women In Vietnam, children are obedient and submissive with their were trained at their community organizations to support parents; they may share information but not attempt to the ongoing process at their children schools. 32 Global Scaling Up handwashing Project The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Lessons Learned The media can serve as a bridge between schools and Strong leadership and political will are effective in scaling community up handwashing practices An integrated media program can be a bridge between schools In Vietnam’s hierarchical society, a very motivated and and the larger community; this is an important aspect of the supportive leader, whether they be the provincial director social ecological perspective. In the case of Vietnam, the same of education, a primary school principal, or a member of messages on handwashing that were emphasized in schools the provincial Women’s Union, can significantly multiply were reinforced through television and the Youth magazine, the program’s achievements. For example, introducing taking the program beyond the schools and into the homes handwashing with soap activities in schools is most effective each evening. if the principal (and Pioneer Team Leader) attends the handwashing with soap training. It is easier and quicker for Accommodate innovation and flexibility in handwashing them to introduce the ideas from the training, especially with soap programs since the principal has influence over the school management Teachers have shown that they can be adaptable and creative board, teachers, students and parents. In Peru, at the when teaching about handwashing with soap, provided that national level, the Ministry of Education has demonstrated they are given the skills to apply new teaching methods and strong commitment to the HWI program by delegating materials such as a teacher’s guide or manual. Training of staff, contributing to the program’s technical development, teachers should focus on building communication skills to enacting regulations, and communicating and supporting the overcome the rigidity of the curriculum and to give teachers process at all education levels. The level of results achieved the skills to be flexible and responsive to the different to date would not have been possible without the political conditions in their schools. will of the Ministry of Education. An example of the power of this commitment is a 2010 guideline on environmental School commitment is greater if participation is on a education for teachers: “Peru, Wonderful Country�, which demand basis includes a chapter on hygiene dedicated mainly to the Formal commitment from schools participating in HWIs promotion of handwashing with soap, and the “educational increases their application of the training and completion of route� developed by the HWI. the handwashing with soap plan for the school. Ample time is needed and support given to assist schools to prepare their Handwashing with soap can influence other projects implementation plan. In Peru, most schools in remote areas, Increasing the impact of handwashing on other projects mainly in the Andes, lack access to appropriate water and and locations is possible when WSP has professionally sanitation facilities. They may have bathrooms but receive researched, prepared, and trialed the package of training water only a couple of hours a day. In most cases water is and materials. In Vietnam, water and sanitation projects distributed by track and stored in cisterns. Teachers are used lack the specialist skills for this work. Influencing is more to organizing healthy corners with water dispensers kept successful if discussions about value-adding take place early within the classrooms. Super Jaboncin was greatly valued in the project cycle so that handwashing with soap can be because of its cost effectiveness because it saving soap by 60 included in project plans and budgets. percent13 and also assigned water for use in handwashing. 13 Reported by the Ministry of Women and Social Development. www.wsp.org 33 The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children Conclusion Conclusion This document has presented two different case studies on increasing handwashing with soap practice by primary school children. Both the Vietnam and Peru programs took place mainly in the primary school setting. The case studies found that formative research on the behavior, beliefs and influences of primary school children is critical for effective behavior change campaigns targeting children. Teachers are also important advocates for handwashing with soap but they need the skills, materials and methodologies to implement handwashing with soap programs in their schools. Beyond the school’s immediate setting, the significance of cultural and contextual factors increased. The degree to which children were agents of change within their families and communities was based on local culture and customs. In Peru, children were important conveyers of messages to the home and they influenced family behavior, while in Vietnam, children’s opinions did not influence adults. In both countries, children were most likely to influence their siblings. The mainstreaming and scaling up of a handwashing with soap program for schoolchildren depended on leadership, policy and institutional setting. Implementing primary school handwashing with soap programs on a national scale required institutional commitment. In Peru, the Ministry of Education was quick to mainstream the program through its national curriculum and policy development, and its regulations. In Vietnam, the Ministry of Education and Training was not ready to take those steps. The program approach was therefore more informal, focusing on extracurricular activities to support the existing curriculum and on collaboration with water and sanitation projects. Regardless of the approach taken, both country case studies demonstrate that getting more children to wash their hands with soap is achievable. 34 Global Scaling Up handwashing Project