Changing Handwashing Behavior for Health Outcomes in Children

My internship in Kenya is with Practical Action, a UK-based organization that is a global innovator, inspiring people to discover and adopt ingenious, practical ways to free themselves from poverty and disadvantage.  More specifically, the project I’m working on is focused on handwashing, it is called the Safe Pair of Hands project (hereafter, SPOH).  This project targets children under 5 years of age through their caregivers and education centers, who live in informal settlements in a major city in Kenya. The goal of the intervention is to improve handwashing of these children in order to reduce rates of diarrhea and malnutrition, and ultimately, child mortality.  Please consider the weight of the following statistics that speak to the importance of handwashing…  

An estimated 5.4 million children worldwide died before reaching the age of 5; more than 68,000 of those child deaths were in Kenya’s region alone; and 6.8% of those child deaths in Kenya were caused by diarrhea.

Unicef, 2018

Diarrhea is “the second leading cause of death in children under 5”. Diarrheal infections are “spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene”.”

World Health Organization, 2017

The good news is that diarrhea is easily treatable through the consumption of vitamins and nutrients that replenish the body, and preventable through good hygiene practice and consumption of clean drinking water.  The bad news though is that these methods are not easily accessible or attainable for individuals living in informal settlements in Kenya.  Kenya, as well as many other “developing” countries, struggles with supplying access to safe water and promoting sanitary hygiene practices  All of these issues revolve primarily around water, and in the sub-Saharan region of Africa where Kenya resides, water is an extremely scarce resource due to the arid climate that provides sparse rainfall and lack of fresh underground water. 

The United Nation’s Sustainable Development Goals (hereafter, SDGs) highlights many of these issues noted above. SDG #6 is dedicated to equal access to clean water and sanitation for everyone; and is vital in achieving SDGs #3, #2, and #1 which emphasize good health and well-being, zero hunger, and eliminating poverty, respectively.  Therefore, Practical Action’s SPOH project works to address four of the global 2030 goals by promoting handwashing of caregivers and children, as well as improving access to running water and soap.  Although improving access to water and soap is quite straightforward, promoting handwashing is quite the opposite.  The focus of this skills-based, handwashing pillar is behavior change communication (hereafter, BCC).  BCC refers to “the whole range of processes and methods used to encourage positive health outcomes by making planned and strategic usage of communication to strengthen health seeking behaviours through health literacy, and can be either focused at the community or individual level” (Sreekumaran Nair, Sarak, et al., 2016)

The “processes” commonly utilized include engaging community members and community leaders in the implementation of the project, aligning communication messages to be culturally-appropriate and effective for the target audience, and incorporating strategies that are evidence- and practice-based.  For the SPOH project, the “processes” include partnering with organizations that provide health care services to children and families, establishing commitments from private water companies to improve access to water for households, engaging community health volunteers that perform household visits to promote handwashing, and involving teachers and managers from early childhood education centers who also promote handwashing in the classroom.  Engaging with these key informants was made easier by having a 10 year-long strong relationship with this community and a history of beneficial projects that provided specific knowledge and learnings needed to inform future projects.  Relationships with stakeholders are critical in being able to provide more than just education in this intervention, and relationships with community members is critical for informing the communication “methods” to be appropriate for children under 5 and their caregivers.  

The “methods” commonly utilized in BCC interventions include direct interventions, mass media, outdoor media, digital technology, social media, and educational materials.  The list of “direct methods” used in the SPOH project are long and far-reaching but the major ones include providing public education sessions on health and hygiene for caregivers of children under 5, extending water pipelines and building more points-of-access taps, providing adequate handwashing stations to education centers, and teaching soap-making skills to community members.  Other “indirect methods” include exposure to children’s handwashing songs, posters that display critical handwashing times, t-shirts for children who participate in hygiene training at schools, lesos for caregivers who participate in community health sessions, and child-friendly murals painted on schools that portray proper handwashing process. 

The more “methods” and “processes” a project can operate, the greater the success the project will have in promoting behavior change, and the best thing about BCC interventions is that they can change and move with the needs of the community.  The SPOH project is a 3-year project and is only 1 year in, in the forthcoming final years the project will employ many more creative BCC interventions.  That is my role as an intern here: to inform the future of the project by generating learning that stems from internal practice and evidence, and external research.  I am within Practical Action’s Monitoring, Evaluation and Learning (MEL) team who are responsible for evaluating projects and generating learning.  The research we are conducting here involves field visits to see the project on the ground, identifying the challenges and key learnings, and proposing evidence- and practice-based solutions to strengthen the project going forward.  My individual research aim is to seek out reports from other organizations who have carried out similar projects and analyze the data to find factors that may improve the SPOH project in Kenya.  For example, I found a report from a program in rural India that used environmental “nudges” in the form of painting stepping stones between latrines and handwashing stations to unconsciously and subliminally persuade children to wash their hands after using the toilets without being actively reminded (Driebelbis et al., 2016).  The success rate was so great that when I shared this with the SPOH team they agreed that if there is possibility for environmental “nudges” in this community, we should implement it into the future BCC plan.  During a field visit I asserted that some of the schools had the appropriate conditions for this idea and soon I will be presenting this recommendation and the supporting research to the entire team.  The opportunity for me to be heard and affect change in such a large organization and important project is incredibly honoring and inspiring.  Being truly valued for the work I do and the input I have to offer keeps me driven and motivated to find solutions to the challenges faced in this project. 

For more information, please visit…



https://data.unicef.org/topic/child-survival/under-five-mortality/ 
 
https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
 
https://practicalaction.org/

References 

Driebelbis, R., Kroeger, A., Hossain, K., Venkatesh, M., & Ram, P. K. (2016).  Behavior change without behavior change communication: Nudging handwashing among primary school students in Bangladesh.  International Journal of Environmental Research and Public Health, 13, 129; doi:10.3390/ijerph13010129

Sreekumaran Nair, N., Sarak, S., et al. (2016). Effectiveness of behaviour change communication (BCC) interventions in delivering health messages on antenatal care for improving maternal and child health (MCH) indicators in a limited literacy setting: an evidence summary of systematic reviews. Protocol. London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London.

United Nations Inter-agency Group for Child Mortality Estimation (2018).  Levels and Trends in Child Morality: Report 2018.  Retrieved on 4 April 2019 from https://data.unicef.org/resources/levels-and-trends-in-child-mortality/

World Health Organization (2 May 2017).  Diarrhoeal disease.  Retrieved on 4 April 2019 from https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease

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