Effect of a Pilot Group Hand-washing Program on Handwashing Behaviors Among Elementary School Children in Assam

Study Overview
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Brief Summary
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The United Nation's International Children's Emergency Fund (UNICEF) is supporting Saba Shikha Abihyan (SSA) (Education-for-All Mission) of the Government of Assam (GoA) under their Water-Sanitation-Hygiene in School (WinS) program to improve WASH facilities, practices and institutionalize WASH in school settings. Under the WinS program, UNICEF piloted a group hand washing program in 100 elementary schools. Multiple past studies have shown that handwashing is an effective intervention to reduce diarrheal diseases and respiratory tract infections, but the evidence on the interventions or programs that can achieve this behavior change is mixed and limited in case of school setting. The main objective of Daily Handwashing for an Ailment-free Life (DHaAL) program was to institutionalize handwashing with soap before consuming mid-day meals and after using toilets among elementary school students. DHaAL is implemented on the Mid-day Meal platform where free meals are given to all students attending government schools. In addition to the standard DHaAL intervention, several pilot phase schools also received an additional program for a holistic and participatory development of school systems for health, nutrition, learning outcomes and wellbeing of children called Child Friendly School System (CFSS). Although CFSS is not a WASH intervention it can develop systems and processes and offer longer support from and implementing agencies which help DHaAL Intervention also. This evaluation study seeks to answer whether DHaAL improved handwashing practice before the mid-day meals in rural lower primary schools as a primary research question. The intermediate outputs and secondary outcomes evaluated in this study include functionality of handwashing infrastructure at school, handwashing practice after toilet use, and availability of and use of handwashing facilities at homes (indirect effect). The evaluation study has other supplemental operations research objectives to help improve the program in future.

Official Title
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Evaluation of DHaAL Intervention of Group Handwashing With Soap Before Mid-day Meals in Rural Elementary School of Assam

Conditions
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Handwashing Behaviors

Intervention / Treatment
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* Behavioral: DHaAL Intervention
* Behavioral: DHaAL + CFSS Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Should be present in the school on the day of interview/survey Exclusion Criteria: None

Ages Eligible for Study
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Minimum Age: 8 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| DHaAL Intervention<br>The group receives standard Ailment-free Life (DHaAL) DHaAL intervention | Behavioral: DHaAL Intervention<br>* This group handwashing program is for rural elementary schools to institutionalize the practice of handwashing before mid-day meal consumption and after use of toilets by harnessing the theory of social peer pressure. DHaAL intervention consists of: (1) capacity building of school teachers to implement group handwashing; (2) installing group handwashing station; (3) generating demand among students to wash hands in group; and (4) establishing systems to sustain handwashing infrastructure and behaviors.<br>|
| DHaAL +CFSS Intervention<br>This group received the standard DHaAL intervention and additional support under another UNICEF program named Child Friendly School System (CFSS). | Behavioral: DHaAL Intervention<br>* This group handwashing program is for rural elementary schools to institutionalize the practice of handwashing before mid-day meal consumption and after use of toilets by harnessing the theory of social peer pressure. DHaAL intervention consists of: (1) capacity building of school teachers to implement group handwashing; (2) installing group handwashing station; (3) generating demand among students to wash hands in group; and (4) establishing systems to sustain handwashing infrastructure and behaviors.<br>Behavioral: DHaAL + CFSS Intervention<br>* In addition to support under DHaAL, several intervention schools receive a more holistic and participatory support that focuses on health, safety, nutrition status, and psychological wellbeing of the children, and thus can also influence handwashing practices (and other WASH facilities). CFSS provides capacity building support and establishes systems to improve school environment, learning outcome, teachers capacity, and physical education for children.<br>|
| Control<br>This group receive the standard / business-as-usual support from the Education Department, but does not receive DHaAL or CFSS Interventions. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of Class 1-5 children washing hands with soap before consuming mid-day meals in schools |  | On the day of interview ( 12-24 months after the external support under DHaAL ceased) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of Class 1-5 children washing hands with soap after the use of toilets for defecation or urination in schools |  | On the day of interview ( 12-24 months after the external support under DHaAL ceased) | 
| Proportion of schools having a functional handwashing station with water and soap |  | On the day of interview ( 12-24 months after the external support under DHaAL ceased) | 
| Proportion of households having a functional handwashing station with water and soap | This is an indirect or spill over effect of the intervention | On the day of interview ( 12-24 months after the external support under DHaAL ceased) |