Feasibility assessment of improved hand and respiratory hygiene intervention in elementary schools of Bangladesh Farhana Sultana Research Investigator WASH Research Group Centre for Communicable Diseases

Background Schools convene many susceptible people together They are efficient settings for the spread of gastrointestinal and respiratory diseases School-based hand and respiratory interventions have the potential to reduce disease transmission Limited infrastructure, funds and maintenance systems to support hygiene practices in Bangladesh (Ref: Neuzil K.M. et al 2002, Stebbins S. et al 2009, Adams J. et al 2009, Xue Y. et al 2012, Freeman M.C. et al 2012, Nasreen S. et al 2010, Nizame F.A. 2011) 2

Hand hygiene interventions tested to date Handwashing with different cleaning agents at important key times Worldwide school-based hand hygiene interventions: Tippy tapsSuper jaboncínSanitizer Soapy water 3 Photo credit: Amy J. Pickering, CARE/Brendan Bannonwww.flickr.comwww.wsp.org

Recommended respiratory hygiene intervention (Ref: CDC, 2013, Barry, T., et al. 2011) 4

Recommended respiratory hygiene intervention In high income countries: Use of tissue/handkerchief observed 3.4% Covering with elbow/arm observed 1.3% Into open air 85% in Bangladesh Lack of evidence and application in low-income countries (Ref: CDC, 2013, Barry, T., et al. 2011) 5

Objectives To pilot an intervention that encourages school children to: - wash hands with soapy water at three key times - use upper sleeves for coughing and sneezing To evaluate the uptake of targeted practices To assess the feasibility and acceptability of the intervention 6

Methods Sample size: 2 urban and 2 rural elementary schools Study sites: urban Dhaka and rural Mymensingh Target population: school children aged 5-13 yrs Study period: May September

Intervention design Training teachers to lead hygiene classes Provision of handwashing stations and behavior change communication materials Formation of a hygiene committee to: - cover cost of soapy water - maintain handwashing stations - promote regular hand and respiratory hygiene practices 8

Handwashing station 40L reservoir with tap Soapy water bottle with metal holder Stand 16L bucket to collect rinse water 9

Soapy water preparation method 10

Handwashing at recommended key times 11

Coughing and sneezing into upper sleeves 12

Data collection techniques 13 Baseline Spot checks of facilities (4)

Data collection techniques 14 Baseline During 1 month follow- up after intervention began Spot checks of facilities (4) Spot checks of facilities (24) Structured observations (24)

Data collection techniques 15 Baseline During 1 month follow- up after intervention began 2 months post- intervention Spot checks of facilities (4) Spot checks of facilities (24) Pocket voting (96) Structured observations (24) Focus group discussions (13) In-depth interviews (5)

Data collection techniques 16 Baseline During 1 month follow- up after intervention began 2 months post- intervention No visits by study team Spot checks of facilities (4) Spot checks of facilities (24) Pocket voting (96) Structured observations (24) Focus group discussions (13) In-depth interviews (5)

Data collection techniques 17 Baseline During 1 month follow- up after intervention began 2 months post- intervention No visits by study team 14 months post- intervention Spot checks of facilities (4) Spot checks of facilities (24) Pocket voting (96) Spot checks of facilities (4) Structured observations (24) Focus group discussions (13) Focus group discussions (14) In-depth interviews (5) In-depth interviews (2)

Data collection techniques 18 Pocket voting exercise with students Focus group discussion with teachers and school committee members

School physical environment Characteristics Urban Rural Govt. School (1) Non-Govt. School (2) Govt. School (1) Non-Govt. School (2) # of students Available toilets4111 Handwashing water source Piped water supply Deep tube-well Shallow tube-well Hand cleansing material at handwashing place before intervention began No During 1 month follow-up Yes 19

Observed and reported practices (1 month follow-up) 20

Subjective, personal and descriptive norm factors 21

Reported knowledge about disease transmission 22

Perceived benefits Handwashing station was: - attractive and child friendly - worked as reminder for handwashing - low-cost - a complete technology with soap and water Both health and non-health benefits motivated students to wash hands “Washing hands with soapy water causes germ free hands.” (One female student of grade IV at a rural school) 23

Using upper sleeves perceived as: - an innovative idea - easy to comply - did not require cost or maintenance Injunctive norms (teachers and peer expectations) motivated students to use upper sleeves “It is a new and easy method of coughing and sneezing that helps me and my friends to remain germ-free.” (One female student of grade V at a rural school) 24 Perceived benefits

Formation of hygiene committee institutionalized the intervention: - Teachers conducted hygiene classes, covered detergent cost along with committee members - Teachers and students encouraged habit formation, and disseminated information to the community - Students and janitors maintained handwashing station “We refill water and prepare soapy water just after arriving at school otherwise students will not be able to wash hands.” (male student of grade V at a rural school) 25 Perceived benefits

Perceived barriers Sometimes the pump of soapy water bottle was stuck Rural school students sometimes missed classes for maintenance Some students did not wash hands/use upper sleeves because: - they were in a hurry to play or go to class - they had not become habituated “The pump needs frequent pressing to get soapy water.” (One male student of grade IV at a rural school ) 26

Observed hand and respiratory hygiene practices (14 month follow-up) 27

Qualitative findings (14 month follow-up) Urban schools stopped using handwashing stations due to lack of maintenance Rural schools continued using handwashing stations: - high perceived benefits - active hygiene committee - involvement of students Using upper sleeves: - new behavior to adopt and sustain - regular promotion required “ Sometime I also cough/sneeze into open air during my classes due to childhood habit, therefore, it is difficult to expect students to remember using upper sleeves.” (One female teacher at a rural school) 28

Conclusion The intervention was acceptable and feasible among school community: - using upper sleeves did not require tissues/water/ soap/maintenance - recurring cost for soapy water was low Schools covered costs after project ended suggestive of sustainability and scalability Short intervention was insufficient to achieve longer- term habit adoption 29

Recommendations Involve education ministry to promote hygiene interventions in schools for sustainability Hygiene committee may appoint and cover the salary of a janitor or provide incentives to students Need to develop and evaluate strategies for sustained habit adoption Further research needed to assess: - scalability and sustainability of the intervention - longer term adoption of habits - impact on health and school attendance 30

Acknowledgements Funding USAID Stanford University Stephen P. Luby JHSPH Peter J. Winch Primary Education Division, Dhaka Kawsar Sabina School community Teachers Students Committee members Janitors icddr,b Leanne E. Unicomb Dorothy L. Southern Fosiul A. Nizame Nadira Sultana Kakoly Md. Mahadi Hasan Md. Mizanur Rahman Shima Sultana Humayun Kabir Anupama Islam Nisho Kishor K. Das Carrie Read For correspondence: 31