School-based Interventions to Promote Personal and Environmental Hygiene Among Children in Pakistan: Protocol for a Mixed Methods Study
Phase: NA
Conditions: Behavioral Assessment of Children, Communicable Diseases in Children
Sponsor: Aga Khan University

Running head: SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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School-based interventions to promote personal and environmental hygiene among children in 
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Pakistan: Protocol for a mixed methods study 
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Nousheen Akber Pradhan1, Waliyah Mughis2, Tazeen Saeed Ali1& Rozina Karmaliani1,3  
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1Department of Community Health Sciences, 2Department of Paediatrics & Child Health, 
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3School of Nursing & Midwifery; Aga Khan University, Karachi, Pakistan 
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Author Note 
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Corresponding author: Nousheen Akber Pradhan – Senior Instructor, Department of Community 
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Health Sciences, Aga Khan University, Karachi, Pakistan nousheen.pradhan@aku.edu  
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This study is funded through the Aga Khan University‘s Faculty of Health Sciences Research 
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Committee. 
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(PF 90/1016) 
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Reviewed by Aga Khan University Ethics Review Committee for granting extension: Feb 2019 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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Abstract 
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Background: Poor personal hygiene and inadequate sanitation practices among young children 
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in LMICs such as Pakistan can lead to critical, life-threatening illnesses such as respiratory 
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infections, diarrheal disease, malnutrition and developmental delays. An intervention for 
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personal/environmental hygiene practices for primary schoolchildren will be implemented at 
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schools in urban squatter settlements of Karachi, Pakistan, aiming to improve the hygiene 
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knowledge and practices (K&P) amongst primary schoolchildren and their mothers, while 
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identifying facilitating and impeding factors in the adoption of hygiene practices for children. 
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Methods: The study will be built on quasi-experimental design with mixed methods data 
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collection approaches. To assess primary grade children and their mothers‘ hygiene-status, K&P 
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survey will be held in the pre-intervention phase. This phase also includes qualitative exploration 
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of mothers‘ and teachers‘ perceptions about children‘s hygiene literacy, factors facilitating and 
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impeding the adoption of the same among school children, for which in-depth guides and focus 
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group discussion tools will be used with teachers and mothers respectively. School physical 
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environmental assessment will be carried out pre-post intervention. This will be followed by 
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multi-component intervention phase with behavior change strategies to improve children‘s and 
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mothers‘ hygiene K&P. The post-intervention phase will assess the intervention effectiveness in 
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terms of enhancing hygiene K&P among schoolchildren and mothers, alongside exploration of 
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mothers and teachers‘ insights into whether or not the intervention has brought changes in 
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improving hygiene practices among children. 
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Results: Paired T-test will be done pre and post intervention to measure the differences in 
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knowledge and practice scores between mothers‘ hygiene literacy and practices with their child‘s 
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knowledge and practices. Similar test will also be run to assess the differences in children‘ 
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hygiene knowledge and practice scores pre and post intervention. (< 50= poor, 50-75=good and 
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> 75= excellent). Thematic analysis will be used for qualitative data. 
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Discussion: Multi-component intervention aimed at improving personal and environmental 
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hygiene among primary school children offers an opportunity to design and test various 
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behavioral change strategies at school and home setting. The study findings will be significant in 
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assessing the intervention effectiveness in improving children‘s overall hygiene. 
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Keywords:  school health program; hygiene practices; Pakistan; hygiene intervention 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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School-based interventions to promote personal and environmental hygiene among children in 
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Pakistan: Protocol for a mixed methods study 
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Background 
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Globally, communicable diseases are prevalent among school age children and the 
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exposure to variety of pathogens causing preventable diseases in school population is inevitable. 
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Underlying factors mainly rests on poor personal hygiene and inadequate sanitation practices [1] 
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leading to school absenteeism and life threatening illnesses among children (if continually 
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neglected in the long run) [2]. The situation is worse in low and middle income countries due to 
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inadequate health care facilities leading to compromised health status of school children [3-5]. 
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Among communicable diseases, respiratory infections and diarrheal diseases are regarded 
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as the deadliest killers of young children [6]. Incidence of diarrheal disease in the initial years 
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has been linked with impaired cognitive performance in the later childhood [7-8].  In addition, in 
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developing countries intestinal helminthic infection is a commonly cited problem among school-
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age children [9-11]. Furthermore, oral health cavity infections are also commonly found in 
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school going children worldwide [4]. Frequent attacks of infection predispose young children to 
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malnutrition and can form a vicious circle and retard children's physical and cognitive 
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development [12]. Moreover, the contextual factors such as poor socio-economic environment 
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further deteriorate the health status of school children especially in low and middle income 
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countries. 
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School children‘s hygiene literacy and practices have therefore received considerable 
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attention to control the spread of infections among this group [13] Because infections due to poor 
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knowledge and unhygienic habits of young children leads to compromised academic 
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performance [12]. Knowledge, attitude and practice (KAP) survey of primary school students in 
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Ethiopia indicated that almost half of the students had adequate knowledge of hygiene. However, 
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the practice of hand washing with soap was not appreciable (36%). [1]. Survey in Palestine 
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showed that 68% of the students reported washing hands with soap after using toilets and after 
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playing and eating [14].  Study in India showed that majority of the students have correct 
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knowledge and practice about hand washing before meals, brushing teeth and washing mouth 
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after eating and combing of hairs; interestingly correct knowledge was not found to be translated 
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with correct practice in all the cases [12]. 
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Schools‘ physical environment also play a crucial role in improving child health. In 
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Nigeria, majority (55.8%) of the school students were dissatisfied about the waste disposal 
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mechanism at school [15]. A study conducted in Ghana indicated lack of hygiene enabling 
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facilities at schools restricted children‘s practice of hand washing despite being knowledgeable 
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[16]. Thus school physical environment has a strong influence on children‘s overall hygiene 
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practices. We found a dearth of school-led studies on promoting environmental hygiene among 
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school children. 
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Various school-based interventional studies have shown improvement in enhancing 
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personal hygiene among school children. A study in Nigeria showed significant improvement in 
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primary students‘ cleanliness after school based health education on personal hygiene [17]. 
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Likewise, India also showed improvement in KAP of school children age 8-10 year olds on 
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various domains of personal hygiene after health education program [18]. Oral health education 
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program in Bangladesh depicted significant improvement in school children‘s‘ (grade 6-8) KAP 
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from baseline alongside reduction in dental cavities [19]. Furthermore, Kenya‘s school water, 
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sanitation, and hygiene (WASH) interventions documented improvement in diarrhea-related 
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outcomes among children under 5 years of age [20]. 
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Apart from school health education and other infrastructure improvement programs, 
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‗Child to child‘ approach has been widely used for improving health outcomes among children 
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[21-22]. In Kenya, children were educated to promote hand washing; they built hand washing 
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stations inside their homes and also persuaded their parents to build latrines [21]. Furthermore, 
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school-based hygiene curriculum has also been used as a strategy to promote hygiene practices at 
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school and at home settings among school children [23]. 
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In the Pakistani context, alongside pneumonia and diarrhea [14] worm infestation [24] 
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and scabies [25] among school age children are the commonly reported health issues; 
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manifesting poor personal hygiene. An evaluation study on water, sanitation and hygiene 
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intervention on school child performance in two cities showed that almost 48% of government 
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school children avoid going to school toilets due to poor sanitary condition [26]. In local context, 
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studies are mostly focused on oral hygiene assessment among children, showing satisfactory 
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knowledge about using tooth paste [27]. Comprehensive assessment about personal and 
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environmental hygiene assessment among children, teachers and parents has remained a gap. 
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Poor knowledge and practice of, and attitudes to personal hygiene have negative consequences 
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on their long term development [28]. This necessitates the designing and testing of school-based 
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interventions aiming to improve hygiene behaviors among children, thereby minimizing their 
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potential to capture preventable illnesses. 
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It is unfortunate that school health remains a neglected aspect of public health in Pakistan 
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[29].  In 2005, School Health Program was launched in 17 districts of the country by Ministry of 
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Education, Pakistan in collaboration with United Nations Educational, Scientific and Cultural 
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Organization (UNESCO). The program focused on various components including personal 
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hygiene and environmental education but its impact was not determined [30]. To the best of our 
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knowledge, there is paucity of studies in Pakistan on school-based interventions to promote 
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personal and environmental hygiene of school children, with child‘s parents and teachers‘ 
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involvement. Towards designing school based programs, role of parents and teachers must be 
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considered as they are the important role models for school going age children. And thus had 
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detrimental effects in shaping children‘s overall health and hygiene behavior.  
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In this paper, we present a study protocol using mixed-methods study design to be 
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implemented in schools of a peri-urban community setting, Pakistan. The proposed study aims to 
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improve the knowledge and practices of school children towards personal and environmental 
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hygiene through school based intervention. To our knowledge, holistic assessment of hygiene 
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among school children has not been studied in the local context. And the intervention to be 
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implemented (with behavior change communication using adult to child and child to child 
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approach, assessment of education curriculum on hygiene concepts) has never been studied 
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before.  
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Primary research questions 
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1. Does school-based hygiene intervention facilitate improvement in knowledge and practices 
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among primary school children studying in semi urban schools, Pakistan? 
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2. What are the enablers and barriers towards the adoption of personal and environmental 
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hygiene practices by school children? 
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Secondary research questions 
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1. Does improvement in knowledge and practices among the mothers of primary school 
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children studying in semi-urban schools contributes to improved knowledge and practices 
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of school children? 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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2. Does school based hygiene intervention contribute in prevalence of communicable 
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childhood illnesses? 
 
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Methods 
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Study design 
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The study will employ a quasi-experimental design (pre-post intervention without control 
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arm). The proposed study design is chosen as it will facilitate in evaluating school based 
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interventions in the selected school settings without randomization. Similar to the randomized 
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trials, quasi-experiments (community based trial) aims to demonstrate causality between an 
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intervention and an outcome at the defined interval [31].  
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Sampling strategy and study participants 
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The sample size of the school children was determined using NCSS Pass version 16 
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software. A sample size of 128 students achieves 80% power to detect a mean of paired 
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differences of 5.0 or more with an estimated standard deviation of differences of 20.0 for 
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knowledge or practices scores and with a significance level (alpha) of 0.05 using a two-sided 
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paired t-test. With 20% inflation to accommodate for refusals and dropouts and after rounding 
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off, the sample turned out to be 256. Universal sampling will be used to obtain a desired sample. 
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To achieve the desired sample size, children studying in primary grade in three schools will be 
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enrolled. Universal sampling will also be used to enroll mothers of the recruited children in the 
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selected schools. 
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Inclusion and Exclusion Criteria for Participants 
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Inclusion criteria for children include, students enrolled in primary grade (class 1-5) only 
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and informed consent given by either of the child‘s parents. After obtaining child‘s parents 
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consent, assent will be obtained from children at the respective school. Children will only be 
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interviewed after obtaining their free will to participate in the study. If consent from child‘s 
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parent and/ assent from child is not obtained, child will be excluded from the study. Once the 
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child gets enrolled into the study, child‘s mother will be approached for her consent to 
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participate. If informed consent is not given, mother will not be part of the study.  For school 
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teachers, those who are available at the time of the study will be recruited after their informed 
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consent. On an average, 2-3 teachers (per school) will be employed in the selected schools. 
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Those teachers who are unwilling to participate will be excluded. 
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In addition, we will also interview District Education Officers (DEO) and District Health Officer 
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(DHO) to explore their perceptions about enablers and barriers for the adoption of hygiene 
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practices among primary grade school children. Interviews with these respondents will only be 
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held after obtaining their informed consent.  
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Study settings 
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The study will be conducted in District Malir, Gaddap town in Karachi, Pakistan. The 
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Gaddap town has 8 union councils with over 400 villages. Male members in the community 
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mainly contribute to household income by working as labors and farmers. Few are also involved 
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in military and protective services. Majority of the married females are housewives and few are 
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employed in health and education sector. Construction of majority of households is pacca. 
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Majority of the households utilize wood as a cooking fuel. Majority of the households fall under 
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lowest to middle wealth quintile. Catchment population usually opts for health care service from 
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private sector due to lack of public sector facilities in the area. Community members mainly use 
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boring as a source of water [32]. Sindh Education Text Book curriculum is followed in the 
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schools. School names are kept anonymous to protect the confidentiality. The government 
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schools charge minimal fees. The cost of the textbooks and other educational expenses are to 
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borne by parents. 
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To achieve the desired sample of school children, three schools in the catchment area will 
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be selected. One of them is the NGO adopted school and other two are government run schools. 
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The schools will be selected upon the recommendation of DEO to improve the hygiene situation 
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in the sampled schools.  
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Data collection methods 
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The study is built on mixed method data collection approaches to gain insight of the 
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hygiene literacy and practices among school children, teachers and child‘s mothers. Table 1 lists 
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different data collection methods with its purpose and interval. 
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Operational definition of personal and environmental hygiene 
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Assessment of personal and environmental hygiene in our study is based on the aspects 
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endorsed by WHO and UNICEF as set of practices and conditions for better health maintenance 
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and prevention of diseases. As defined by Boot and Cairncross (1993), hygiene is ―the practice of 
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keeping oneself and one's surroundings clean, especially in order to prevent illnesses or the 
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spread of diseases‖ [33]. 
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In addition, a set of hygiene indicators assessed by earlier studies [1, 11, 12, 14, 16, 26, 
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34-35] were also referred and incorporated in this study [Refer to Table 2]. 
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Study phases 
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The study has been structured into 3 phases – pre-intervention, intervention and post-
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intervention. 
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Phase I: Pre-intervention Phase  
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Before data collection, community stakeholders (teachers and school management) will 
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be taken on board and information pertaining to the overall scope and objectives of the study will 
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be shared with them. Meetings with community and school leadership will remain a significant 
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step to seek their cooperation throughout the study. All data collection tools will be translated in 
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the local languages (Urdu and Sindhi). This phase will also involve pre-testing of all the data 
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collection tools in the neighborhood school in the catchment area. After pre-testing, necessary 
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modifications will be carried out in the tools.  
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Quantitative data collection  
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Survey of school children and mothers 
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The quantitative data collection instruments include two closed-ended survey 
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questionnaires (for students and mothers). Survey questionnaire for children include questions to 
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gauge child‘s knowledge and practices on basic personal and environmental health aspects at pre 
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and post intervention phases of the study. Aspects under personal hygiene include: hand washing 
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(pre-post eating, use of toilet, after playing), bathing, tooth brushing, nail hygiene, sneezing, 
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washing fruits and vegetables before consumption and drinking boiled water. Whereas, the focus 
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on environmental hygiene is on the knowledge and practices related to throwing and spitting 
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garbage in the environment and its health effects. Children will be interviewed at the school. 
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On the other hand, survey questionnaire for mothers include questions about socio-
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demographic information (including age, qualification, occupation, income, household assets 
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etc.). For demographic information, PDHS 2012-2013 [36] survey tool was adapted. Followed 
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by the demographic questions, mothers will be particularly enquired about their knowledge and 
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practices related to personal and environmental hygiene. Mothers will also be questioned about 
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whether the child suffered from communicable illnesses one month prior to the survey. This 
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includes diarrhea, pneumonia, scabies, oral health infections, typhoid, malaria, hepatitis and 
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mosquitoe borne illnesses. In addition, the questionnaire will also assess the hygiene habits of 
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their child. In case of more than two children belonging to same mother, she will be enquired 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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about the hygiene habits of a child through random selection. Interviews with mothers will be 
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held at their homes.   
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Assessment of school physical environment 
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Role of school in promoting hygiene behavior among school children will be assessed by 
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observing the physical environment. The observations will be categorized as present and absent 
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with comments in six domains. This includes: general maintenance and waste disposal, hand 
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washing facility, toilet hygiene, drinking water facility and hygiene behavior of school children. 
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The checklist has adapted from US environmental assessment checklist for healthy school and 
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water and sanitation standards for schools in low cost setting. [37] 
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Qualitative data collection 
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This involves four tools (1) checklist to review the school education curriculum (2) 
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School Hygiene assessment checklist (3) In-depth interview guide with school teachers, DEO 
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and DHO and (4) a Focus group discussion (FGD) interview guide for mothers. 
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School Education Curriculum checklist has been designed to assess the integration of 
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basic health and hygiene aspects into the primary education curriculum (Sindh Text Book of 
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class 1-5 grade). The assessment will revolve around whether or not key themes on personal and 
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environmental hygiene are integrated into the curriculum, which strategies are utilized to 
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increase hygiene literacy in children (such as use of pictures or text only), whether or not the 
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curriculum sensitizes the children that unhygienic condition will lead to illnesses/ sicknesses. 
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Furthermore, while reviewing the curriculum, structure of the language will also be examined in 
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its simplicity and being captive in attracting children‘s attention. All the findings will be 
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documented on MS Word with columns having the above components. The observation checklist 
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has been adapted from the curriculum integration and instruction alignment guide [38].   
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In-depth interviews (IDIs) will be carried out with school teachers in the selected schools 
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(associated with teaching in the primary section) and representatives in District Education and 
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Health office. The purpose of IDIs with these stakeholders will be to explore their perception 
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about hygiene literacy and practices in school children. In addition, IDIs will also be meaningful 
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in exploring key stakeholders‘ views on existing health promotion activities in the school to 
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promote child‘s behavior. An estimated length of the IDI will be 30-40 minutes. The interviews 
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with DEO and DHO will be meaningful to unfold their role in health promoting activities at the 
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school and the collaboration if any exists between the two sectors. 
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FGDs will be carried out with mothers of school children. To facilitate interview process, 
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a FGD guide has been developed. FGDs will be instrumental in exploring mothers‘ views on 
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health and hygiene, their knowledge and practices about hygiene and also their children‘s 
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hygiene practices. In addition, FGD would also explore perceptions of mothers on innovative 
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strategies to promote knowledge and practices of school children related to personal and 
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environmental hygiene. Approximately 2-3 FGDs with mothers will be carried out per school. 
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Number of FGDs will be increased keeping in view data saturation. Setting for the FGD will be 
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decided in consultation with the mothers. A group of 6-12 mothers will be expected for a single 
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FGD. 
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IDIs with teachers and other stakeholders and FGDs with mothers will be pivotal in 
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exploring their views on ‗what can work and what cannot towards enhancing personal and 
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environmental hygiene‘ among school children. The perceptions and opinions collected during 
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the FGDs will be meaningful in modifying the intervention package. 
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Separate interview guides for teachers and mothers have been developed with probes to 
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facilitate the interviews process. Information on the survey form will be filled by data collectors, 
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whereas IDIs and FGDs will be conducted by the Principal Investigator and Co- Investigators. 
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The data will be obtained in the local languages (Urdu and Sindhi). 
 
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Phase II: Intervention Phase 
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Multi-component intervention package has been designed aiming to improve personal 
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and environmental hygiene of children utilizing behavior change communication (BCC) 
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approaches. 
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The intervention phase (expected to last for 3-4 months) has been conceptualized by 
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utilizing Albert Bandura‘s social learning theory [39]. 
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The theory postulates that learning take place within a social context with three different 
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modeling stimulus (live models, verbal instructions and symbolic). Demonstration through live 
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models will be carried out in front of children by teachers and also through role-plays by senior 
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students. Series of verbal health sessions will be held with the students using health education 
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material. In addition, environment will be made symbolic to learn and practice hygiene behavior 
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through display of information, education and communication (IEC) material and through 
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organizing role plays and drama at the school. In addition, various behavioral and cognitive 
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processes will be given attention. This includes, making children attentive to learn through 
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different teaching and learning strategies. Retention of key concepts will be done by repeating 
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the sessions at frequent intervals. To motivate children to practice hygiene behavior, school 
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environment will be made conducive and children will be encouraged by the school teachers to 
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practice and demonstrate the learned behavior. Refer Fig 1. 
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The intervention phase seeks to involve the community stakeholders in planning and 
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implementation. Alongside ‗adult to child‘ approach, notion of ‗child to child‘ approaches [21-
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22] in behavior change communication will also be embedded in the intervention.  Refer to table 
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3 for the details of the intervention package. Field manual for the intervention module will be 
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developed to ensure adherence to the proposed intervention. The intervention will be 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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administered by the Principal Investigator and Field Team who will be thoroughly trained in 
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using the intervention modalities. 
 
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Phase III: Post Intervention  
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Post-intervention phase will determine the effectiveness of the school based intervention 
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by measuring the level of change in the hygiene literacy and practices of school children and 
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mothers through survey questionnaire. In addition, mothers will be once again assessed on the 
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prevalence of communicable diseases among their children as assessed in pre-intervention phase 
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(as used in Phase I). 
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Perceptions of mothers and teachers will also be gathered on how well the intervention 
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modalities worked at the respective school settings and respondents‘ perceptions of the 
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intervention in influencing children‘s hygiene knowledge and practices. Inspection of school 
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physical environment will also be carried out to ascertain improvements in the health promoting 
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environment using physical environment assessment checklist. 
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Across all phases of the study, Principal Investigator and Co- Investigator will randomly 
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visit the field sites to ensure monitoring of data collection and implementation of intervention 
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modalities. Feedback will be shared with the field team to ensure strict adherence to the data 
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collection steps and intervention aspects. Data collection forms, interview recordings and 
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transcripts will be safely stored with Principal Investigator in local and key with access to 
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research team for data analysis. 
 
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Data Analysis 
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Quantitative data derived from survey questionnaires will be entered in EPI Data version 
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3 and will be analyzed in SPSS 19.0. Proportions will be reported to present knowledge and 
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practices for children personal and environmental hygiene. Proportions will be categorized in to 
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knowledge and practices domains under personal and environmental hygiene. Mean proportions 
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will be then converted into scores. Scoring criteria includes (< 50= poor, 50-75=good and > 75= 
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excellent). The scoring criterion has been customized for the purpose of analysis. 
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The McNemar test will be used to analyze the differences in the proportions for 
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knowledge and practices of school children before and after the intervention. Similar test will 
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also be applied to analyze the differences between children and their mothers before and after 
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intervention. Paired T-test analysis will also be done pre and post intervention to measure the 
328 
differences in knowledge and practice scores between mothers‘ hygiene literacy and practices 
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with their child‘s knowledge and practices. In addition, paired T test will also be used to assess in 
330 
difference in the prevalence of communicable diseases among children pre and post intervention. 
331 
Similar tests will also be run to assess the differences in children‘ hygiene knowledge and 
332 
practice scores pre and post intervention. Changes in knowledge and practice of school children 
333 
regarding hygiene will be assessed. There are no sub-scales used in the study.  All knowledge 
334 
and practice related responses will be measured as scores (pre-post intervention).  Scores will be 
335 
summed together. Less than 50 will be considered as poor, minimum and maximum score for rest 
336 
of the categories are 50-75 will be considered as Good and 75-100 as Excellent. Higher values in 
337 
each of the three categories will represent better outcomes for knowledge and practice 
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This will include assessment of the change in the prevalence of communicable diseases 
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(diarrhea, typhoid, pneumonia, oral health infections, scabies, hepatitis and mosquito borne 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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infections) through structured questionnaire. Proportions of the children with these conditions 
341 
will be used to report the change. No scales or sub-scales will be used. Proportions specific for 
342 
each diseases will be averaged out pre-post intervention study. 
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Qualitative data including FGDs (with mothers) and IDIs (with school teachers and 
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District Education and Health Officers) will be recorded and transcribed verbatim. Data will be 
345 
manually analyzed. Thematic analysis will be manually carried out in accordance with steps 
346 
described by [40]. Refer Fig 2. Text will be read several times to develop in-depth understanding 
347 
of the data. Meaning units (recorded text) will be read several times to identify the codes (short, 
348 
meaningful descriptions). Similar codes will be then clustered into groups called ―categories‖, 
349 
which will be later classified into themes. Themes generating from the data set will represent the 
350 
latent content (the underlying meaning of the text) and relationships among the categories. 
351 
Data from qualitative and quantitative approaches will be triangulated for analysis at the 
352 
end of the post-intervention phase. In order to obtain a comprehensive understanding of the 
353 
hygiene literacy and practices among children and whether or not school based intervention has 
354 
positively improved knowledge and practices of children, information from multiple sources 
355 
(surveys, FGDs, IDIs, school physical environment assessment and education curriculum 
356 
review) will be triangulated. 
357 
Discussion 
358 
Communicable diseases among school children remains a highly prevalent issue in 
359 
LMICs such as Pakistan [41-43]. School and home are two of the primary settings to be 
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considered to plan and implement behavior change communication about hygiene [43-44]. The 
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described protocol of the current study aims to test the effectiveness of school-based hygiene 
362 
interventions to improve the knowledge and practices of school children in urban squatter 
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SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
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settlements in Pakistan. The intervention will be conducted at three schools (one NGO-adopted 
364 
and two government-managed schools) in urban squatter settlement with multiple stakeholders‘ 
365 
involvement (teachers, school management, schoolchildren and their mothers). 
366 
Maternal knowledge and practices, as well as those of school teachers, have been shown 
367 
to play an imperative role in improving hygiene practices of children [46-47]. During baseline, 
368 
FGDs and IDIs will be conducted with mothers and teachers respectively to seek their 
369 
perspectives about children‘s health and hygiene literacy and practices. Their opinions regarding 
370 
positive and negative influences on children‘s hygiene practices at school and home will also be 
371 
sought. Additionally, the school physical environment will be audited to inspect the availability 
372 
of soap and appropriate hand-washing facilities, general cleanliness, adequate garbage disposal 
373 
facilities, etc. for the students and staff at the school premises. During the intervention phase, 
374 
participatory sessions will be organized with teachers to obtain their feedback on the intervention 
375 
package. And teacher‘s capacity building session will be carried out to help them facilitate 
376 
hygiene awareness sessions at the school. In addition, behavior change sessions for mothers will 
377 
also be conducted at their homes. The study also attempts to analyze the existing school 
378 
educational curriculum and examine the extent to which it incorporates hygiene principles.  
379 
The effectiveness of the intervention will be gauged through an end line survey of 
380 
children‘s knowledge and practices, and also by capturing mothers and teachers‘ perceptions on 
381 
how the school-based intervention improved the overall hygiene literacy and practices of 
382 
children. Use of multiple data collection tools will facilitate us to validate our findings and 
383 
assumptions about the children‘s hygiene knowledge and practices. 
384 
Principles of Bandura‘s social learning theory are incorporated into the study‘s 
385 
intervention phase to reinforce children‘s hygiene practices through use of different modeling 
386 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
21 
stimuli (live modeling, symbolic and verbal instructions) and through different behavioral and 
387 
cognitive processes which can potentially influence the adoption of hygiene behavior among 
388 
children. Adequate knowledge about hygiene practices will be reinforced at frequent interval at 
389 
the study settings. 
390 
To the best of our knowledge, earlier studies aiming to improve hygiene literacy and 
391 
practices at schools have not taken the holistic approach as conceptualized in this research 
392 
protocol. This study therefore intends to undertake a comprehensive assessment of hygiene by 
393 
not only assessing children‘s knowledge and practices, but also by understanding the enablers 
394 
and barriers of hygiene knowledge and practices for school children through teachers and 
395 
mothers.  And by undertaking a comprehensive assessment of school physical environment and 
396 
educational curriculum. A limitation of the study lies in not involving fathers and by not doing a 
397 
spot check of children‘s hygiene behavior at the school.  
398 
The study findings would be would be useful in proposing changes in the school 
399 
curriculum to incorporate hygiene concepts, educating the hygiene principles at the school and 
400 
ways to improve the school‘s physical environment for children to practice hygiene behavior. In 
401 
addition, findings will also indicate the hygiene aspects which must be emphasized at the school 
402 
and home settings for improved knowledge and practices for school children. 
 
403 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
22 
Abbreviations 
404 
AKU: Aga Khan University 
405 
BCC: Behavior Change Communication 
406 
DEO: District Education Officer 
407 
DHO: District Health Officer 
408 
ERC: Ethics Review Committee 
409 
FGDs: Focus Group Discussions 
410 
IEC: Information, Education and Communication 
411 
IDIs: In-depth interviews 
412 
KAP: Knowledge, attitude, practices 
413 
K&P: Knowledge and practices 
414 
LMICs: Low-middle income countries 
415 
NGO: Non-governmental Organization 
416 
PDHS: Pakistan Demographic and Health Survey 
417 
WHO: World Health Organization 
418 
UESCO: United Nations Educational, Scientific and Cultural Organization  
419 
UNICEF: The United Nations International Children's Emergency Fund 
420 
USAID: United States Agency for International Development 
 
421 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
23 
Declarations 
422 
Ethics approval and consent to participate 
423 
The study has received ethical approval from Ethics Review Committee (ERC),  Aga 
424 
Khan University (AKU) (5013 CHS- ERC-17). Approval will be obtained from the selected 
425 
schools administration (NGO adopted school and two government run schools) before initiating 
426 
the data collection. Consent from research participants (mothers, teachers, DHO and DEO) will 
427 
be requested to participate in the study. Upon obtaining consent from mother, child‘s assent will 
428 
be taken. Consent forms are designed for this purpose. Approval process will include verbal 
429 
explanation to the participants about the purpose of the study and data collection methods 
430 
followed by their written approval in form of signature/ thumb impression (for illiterate 
431 
participants). Consent from mothers and children will be taken by the data collectors, on the 
432 
other hand consent for qualitative interviews (FGDs and IDIs) with mothers, teachers and key 
433 
informants will be obtained by the Principal Investigator. While obtaining study participants‘ 
434 
consent, their anonymity of comments and responses will be also be ensured. All participants 
435 
will also be provided with an ERC, AKU. 
436 
 
437 
Consent for publication 
438 
Consent for publication of the findings has been stated in the consent forms. 
439 
Availability of data and material 
440 
The data collection tools developed/ adapted in the study and all data sets will be 
441 
available upon request. Please note that there are no formal publicly available repositories in 
442 
Pakistan for research manuscripts. Supporting data files will be shared if needed by the Journal 
443 
Editors. 
444 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
24 
Competing interests 
445 
There are no competing interests to declare. 
446 
Funding 
447 
This study is funded through the AKU, Faculty of Health Sciences Research Committee 
448 
(PF 90/1016). Funder has reviewed the overall study and their comments were incorporated 
449 
before getting final approval. Funding is approved for all the activities related to data collection, 
450 
hiring of human resources, designing and implementation of intervention etc. The grant does not 
451 
cover funds for publication fee charges.  
452 
Authors’ contributions 
453 
NAP is the Principal Investigator. NAP in consultation with TS and RK has designed the 
454 
study protocol. NAP has written the manuscript. Alongside NAP, WM has contributed in writing 
455 
various sections and formatting of the manuscript. All authors have reviewed the manuscript. 
456 
Acknowledgements 
457 
The authors would like to acknowledge Ms Naseem Hashmani for translating the study 
458 
tools and Mr Issa Khan in providing the needed logistics assistance in identification of field sites.  
459 
Authors’ information 
460 
Nousheen Akber Pradhan - Senior Instructor, Department of Community Health 
461 
Sciences, Aga Khan University – nousheen.pradhan@aku.edu 
462 
Waliyah Mughis – Research Associate, Department of Paediatrics & Child Health, Aga 
463 
Khan University Hospital – waliyah.mughis@aku.edu 
464 
Tazeen Saeed Ali – Associate Professor & Assistant Dean, School of Nursing & 
465 
Midwifery, Aga Khan University – tazeen.ali@aku.edu 
466 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
25 
Rozina Karmaliani – Professor, School of Nursing & Midwifery, Aga Khan University – 
467 
rozina.karmaliani@aku.edu  
468 
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470 
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597 
 
598 
 
599 
 
600 
 
601 
 
602 
 
603 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
31 
Figure 1: Albert Bandura‘s Social Learning theory to promote hygiene behavior among school 
604 
children 
605 
 
606 
 
607 
 
608 
 
609 
 
610 
 
611 
 
612 
 
613 
 
614 
 
615 
 
616 
 
617 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
32 
Figure 2: Graneheim & Lundman‘s qualitative data analysis process 
618 
 
619 
 
620 
 
621 
 
622 
Table 1: Data collection methods 
623 
 
624 
Serial 
Number 
Tools 
Purpose 
Frequency 
1.  
Survey questionnaire for 
children 
 Assess the level of 
hygiene 
knowledge and 
practices among 
children at 
baseline & end-
line 
 Assess the level of 
mothers‘ own 
hygiene 
knowledge and 
practices and also 
of their children at 
baseline and end-
line 
 Baseline and end-
line 
2.  
Survey questionnaire for 
mothers 
 
Meaning 
units 
Codes 
Categories 
Themes 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
33 
Serial 
Number 
Tools 
Purpose 
Frequency 
3.  
Interview guide for FGD with 
teachers and mothers 
 Explore enablers 
and barriers on 
school-based 
interventions to 
promote personal 
and environmental 
hygiene practices 
among children 
Baseline and end-line 
4.  
School physical environment 
observation checklist 
 Assessment of 
school physical 
environment to 
promote hygiene 
practices in 
children 
Baseline and end-line 
5.  
Checklist to review 
educational curriculum 
 Assess the 
integration of 
basic health and 
hygiene aspects in 
primary education 
curriculum 
Baseline 
 
625 
 
 
626 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
34 
Table 2: Operational definitions of hygiene indicators 
627 
 
628 
S# 
Hygiene indicator 
Operational definition 
1.  
Personal hygiene 
1. Drinking 
boiled/filtered water 
2. Hand-washing (pre 
and post meal, after 
defecation, after 
playing outdoors) 
3. Tooth brushing with 
toothpaste 
4. Keeping nails 
trimmed/short 
5. Covering mouth with 
elbow while sneezing 
6. Taking bath regularly 
at least once daily 
7. Washing fruits and 
vegetables before 
eating  
2.  
Environmental hygiene 
1. Not spitting on streets 
2. Not throwing 
garbage/waste on 
streets 
3. Maintaining 
cleanliness of school 
toilets 
 
629 
 
630 
631 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
35 
Table 3: Intervention package to improve hygiene literacy and practices among primary 
632 
grade school children & their mothers 
633 
Serial 
Number 
Interventions 
Frequency 
Platform/ channel 
of communication 
1.  
Capacity building of master trainers (school teachers and children) 
1.1 Teachers‘ training/refresher sessions 
will be arranged to enhance hands on 
skills for educating children about 
improving personal and environmental 
hygiene 
Once during the 
intervention 
phase and 
refresher 
sessions will be 
arranged as per 
need 
Training sessions per 
school through using 
audio and visual 
(AV) aids 
1.2 Pool of children with good leadership 
skills will be selected from the school and 
will be trained in educating others on 
personal and environmental hygiene 
concepts 
One time activity 
of selection of 
children 
 School settings 
2.  
Health awareness sessions by master-trainers at the school settings 
2.1 Children will be educated about the 
need for hygiene and how to take care of 
personal and environmental hygiene. 
These sessions will be organized by 
teachers 
 Once a week 
for4- 6 weeks. 
Use of posters and 
graphics in local 
language 
2.2 Role plays and awareness raising 
sessions by the children (senior students) 
to promote hygiene among students 
Once every 2 
weeks 
Role plays and 
theatre 
2.3 Awareness raising sessions for 
mothers conducted and organized by 
teachers and health workers, on practice 
for personal and environmental hygiene 
Once every 2 
weeks for 4 
weeks 
Pictorial 
presentations in 
local language 
3.  
Promoting hygienic environment at schools 
3.1 Environment will be made conducive 
through AV aids to foster hygiene habits 
among children 
To be displayed 
during the entire 
intervention 
phase 
Cartoon character 
practicing hygiene 
habits, and posters 
with hygiene 
messages  
3.2 Improvement in the school physical 
environment such as placing garbage 
disposal bins, ensuring availability of 
soap at the handwashing facility 
 
Dissemination of the 
findings from 
baseline to school 
administration 
4.  
Reinforcement of hygiene concepts to children 
4.1 Reinforcement of hygiene concepts to 
children will take various forms, such as 
asking children to mention what they 
Once every 2 
weeks for 4-6 
weeks 
Hygiene diary, 
hygiene games, 
hygiene quiz 

SCHOOL-BASED HEALTH HYGIENE INTERVENTION 
36 
Serial 
Number 
Interventions 
Frequency 
Platform/ channel 
of communication 
have learnt by documenting it in their 
hygiene diaries, involving them in 
hygiene games, organizing hygiene 
quizzes at school 
5 
Health literacy session for mothers 
 
 
5.1. Mothers of school children will be 
sensitized on hygiene aspects through 
group discussion  
Thrice in  the 
entire period 
Health education 
flyers and posters to 
be used during 
group discussion at 
home/ school 
settings 
 
634 
 
635 
 
636 
 
637 
 
638 
 
639 
 
640 
 
641 
 
642 
 
643 
 
644 
 
645 
 
646 
 
647