Studies carried out worldwide have shown that provision
of safe water and sanitation facilities can only optimize
a reduction of water and sanitation related diseases if
sustainable changes in hygiene behaviour are achieved.
Adoption of new behaviour is a difficult task in itself. The
major objective of the Water and Sanitation Extension
Programme (WASEP) is to significantly reduce diarrhoeal
incidence in partner villages located in northern Pakistan.
In order to achieve its objective, WASEP has been striving
hard to bring about behavioural changes at grass-roots
level, in addition to assisting communities to establish safe
water and sanitation facilities. One of the most important
initiatives towards this end has been the promotion of
healthier behaviour through primary schools. This paper
will describe and share the need, development and implementation,
impact, and issues related to this initiative in the
context of northern Pakistan

Karim Alibhai (7222241)

Tameez Ahmad (7217618)

English

Loughborough University Institutional Repository

ALIBHAI and AHMAD166		 	Dr. K Alibhai and Dr. T Ahmad, Pakistan ! "# $%"% &""&'"'STUDIES CARRIED OUT worldwide have shown that provi-sion of safe water and sanitation facilities can only optimizea reduction of water and sanitation related diseases ifsustainable changes in hygiene behaviour are achieved.Adoption of new behaviour is a difficult task in itself. Themajor objective of the Water and Sanitation ExtensionProgramme (WASEP) is to significantly reduce diarrhoealincidence in partner villages located in northern Pakistan.In order to achieve its objective, WASEP has been strivinghard to bring about behavioural changes at grass-rootslevel, in addition to assisting communities to establish safewater and sanitation facilities. One of the most importantinitiatives towards this end has been the promotion ofhealthier behaviour through primary schools. This paperwill describe and share the need, development and imple-mentation, impact, and issues related to this initiative in thecontext of northern Pakistan.		With the full implementation of water and sanitationprojects, WASEP initiated a health and hygiene educationprogramme focussing mainly on women. Post-evaluationof the initiative after one year of implementation, revealeda significant impact on adoption of healthier behavioursand reduction in diseases (Ahmad and Alibhai, 2000).However, monitoring results showed that special attentionhad to be provided to school going children as certainunhealthy behaviours were common among them. Some ofthese behaviours were: (i) reticence in using latrines, (ii)lack of handwashing after defaecation, (iii) drinking fromopen channels despite availability of tap water nearby, (iv)eating unwashed fruit, and (v) eating without washing hands.Majority of women expressing their views on the aboveissues said that their school going children weren’t adopt-ing health and hygiene education messages conveyed tothem. One of the major reasons cited was the perceptionthat children apparently have more knowledge than theirmothers “who were uneducated.” Keeping in view thedemand of the communities for educating and involvingschool going children in the process of behavioural change,and recognising that promotion of healthier behavioursthrough school children will maximise the benefits of waterand sanitation projects, WASEP launched an initiative ofthe School Health Improvement Programme (SHIP) in itspartner communities. The promotion of hygiene behaviourthrough SHIP, is based on the assumptions that (i) childrencan act as role models, (ii) children can take action toprevent ill health, (iii) children can easily spread theirknowledge to others, (iv) they can influence their parentsand siblings, and (v) it is easier for children to adopt newbehaviours than older people and hence they can bringsustainable changes in future. Since children in the agegroup of 8-15, are responsible for helping mothers intaking care of younger children. Therefore, adoption ofhealthier practices by younger children, especially girls, ishighly desirable to reduce the risk of water and food bornedisease among children under five years of age. Analysis ofbaseline data collected in partner villages for age wisedistribution of diarrhoeal cases revealed that childrenunder five years of age as most vulnerable age group. If weinclude the next age group, then 80 percent of all diarrhoealcases are in the age group below 15 years and only 20 %in age group above 15 years old. This data clearly depictsthe need to include young children in the process ofpromotion of healthier behaviours.A curriculum for SHIP, at primary school level, wasdeveloped based on Child to Child (CtC) approach in closecollaboration with the Institute for Educational Develop-ment (IED), Aga Khan University, Karachi, with an overallobjective of facilitating adoption of healthier behavioursby involving children in all phases of behavioural changefrom planning to evaluation. The curriculum consists ofeight topics: (i) Clean Hands, (ii) Children’s Stools andHygiene, (iii) Clean, Safe Water, (iv) Diarrhoea: Causes,Prevention and Cure, (v) Intestinal Worms, (vi) Clean, SafeFood, (vii) Personal Hygiene, and (viii) Management Issuesrelated to O&M of WSS (Ahmad and Jina, 2000). Thecurriculum is designed to make use of active teachingmethods such as group discussion, stories, role-playing,and cartoons. Each topic is objective oriented and designedto disseminate its message based on knowing, doing andfeeling. One of the important characteristics of the curricu-lum is that it allows children to determine the problems bythemselves and subsequently think, plan, take action andmonitor the outcome. The curriculum allows children totranslate ideas into creative activities and understand healthand hygiene. In order to implement the curriculum, inten-sive training was provided to Health and Hygiene Promot-ers (HHPs) of WASEP.ALIBHAI and AHMAD167G46									G46	G46G46G46		G46	G46		G46 G46!"#$%G46&%%G46'%(G46%%)G46**+G46'(*G46(%)G46,%(G46&!"#$+&G46()'G46)-'G46.)'G46'%,G46%-)G46+),G46%-.G46'	SHIP was implemented in more than 100 schools locatedin partner villages, where more than 1500 sessions wereconducted. As a result of this initiative, different actorssuch as teachers, parents, and WASEP staff felt that apositive impact had occurred by involving children in thepromotion of healthier behaviours. For measuring theimpact of the initiative various methods such as KAPsurveys before and after intervention, interviews withmothers and teachers, independent evaluation by teachersthemselves, and direct observation of certain behaviourswere employed.				Observations made during the household visits revealedthat children had shared their new knowledge with othercommunity and family members. Students had also sharedstories that they had learned during the sessions with theirfriends while playing outside. During a household visit, amother said, “…although my 6 years old child was notattending your sessions, he told me everything about whatyou taught other children in the school as he learned allthese from other children.”  A village girl narrated to theHHP, “ what do you teach in schools; my brother alwaysgive advice to family members about cleanliness of houseand personal hygiene. He keeps soap near water channeland washes his hands with soap and forces others to usesoap for handwashing. He says that we get diseases if we eatfood without washing our hands”. More or less in allvillages children conveyed messages to others (communitymembers) especially non-school going children throughroles plays, posters, and stories. Students from non-projectsvillages also shared messages with others in their respectivevillages. During a recent baseline KAP survey in a newselected village for intervention, when a woman was askedhow did she know causes and prevention of diarrhoea andintestinal worms, she said, “ I learnt all these from my childwho is going to a school located in other village calledGram” (a partner village selected in 1999 for interventionwhere SHIP was implemented a year ago). Sample pre andpost KAP surveys conducted in six schools indicated thathealth knowledge of children greatly improved: knowledgeof making ORS increased from 6.5% to 75.4 %; thepercentage of students considering running water entirelysafe dropped from 66.3 % to 23.2%. Table 1 shows resultsof the pre and post intervention for some of the indicators.While interpreting results, it should also be noted that postKAP surveys also include students who hadn’t directlyparticipated in SHIP sessions (i.e., they were at Class II whileSHIP sessions included students from Class 3 to Class 5).	As part of their independent research activity, studentsobserved many incidences of open defaecation in the streetsaround their homes. In Hopay, SHIP students organized acampaign to safely dispose of the faeces (burial) andimprove the village environment. A group of girls inBroshal initiated a community beautification project fol-lowing a SHIP session by collecting and sanitarily dispos-ing of solid waste from the village, and sweeping the streetsaround their homes. In Shishkat, children brought soap tothe school after attending session on handwashing on theprevious day, and said, “at home we wash our hands withsoap but what would we do in the school, that is why wehave brought soap with us.” In Datuchi, students have beenmaintaining cleanliness of streets and general environmenton regular basis. In Barkolti a child motivated his fatherand elder brother to dig a pit for defaecation and in just oneday they dug a pit and covered it with wooden sticks,making squatting hole in the middle as an immediatesolution to open defaecation. In some schools, teachersreported that students played active roles in construction oflatrines for schools. Interviews with parents revealed thatchildren also tried to motivate their parents to a buildALIBHAI and AHMAD168G46// 1234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234561234560!$0!$,),(,%,*,-,,1 2-.	121212-.%)-&+.household latrine. However, it should be appreciated toquantify how many extra latrines were built at communitylevel due to promotion efforts undertaken by childrenalone. Latrine coverage at community level increased froman average value of 70% for 1998 partner villages (with noSHIP intervention) to 85% in the case of 1999 partnervillages (with SHIP intervention) despite reduction in sub-sidy for 1999 partner villages. The near 20 % increase inlatrine coverage in the case of 1999 partner villages par-tially could be attributed to efforts undertaken by schoolgoing children to promote sanitation at community level.As a result of SHIP, children proved themselves effectivemonitors of hygiene behaviour at household and commu-nity level. In many villages when WASEP compared moni-toring data collected through interview with women to thatcollected by children using observational technique, it wasfound that children’s findings presented relatively truepicture of the prevailing situation. For example, groupdiscussions with women on handwashing practices duringbaseline surveys revealed that a huge majority of familymembers washed their hands with soap after defaecationand before eating. In contrary, children data collected athousehold level on a previous day recall revealed a differentpicture i.e., only 6 % of people washed their hands withsoap. As a result of sharing children findings with them,women altered their answers to provide a picture moreconsistent with the children’s findings. Realising the effec-tiveness of children in monitoring, WASEP provided anopportunity to children to conduct pre and post surveys onhandwashing practices. The data collected by childrenfrom six schools located in three partner villages onhandwashing practices at baseline and after 19 months ofintervention is shown graphically in Figure 1. As can beseen from the figure handwashing with soap before eatingand after defaecation increased from a baseline value of19% and 15 % to 62 % and 79 % respectively showingsignificant increase in the usage of soap.		About 9 months after implementation of SHIP, teachersrepresenting 20 schools participated in a workshop toevaluate the effectiveness of the initiative. For this purposeten indicators were selected and each teacher graded changein selected indicator using a scale graduate from 1 to 5 torepresent the situation before and after SHIP. The results ofthe evaluation for the selected indicators are shown inTable 1. As can seen from the table children’s cleanlinessincreased from 2 to 4 giving 100% improvement. Theoverall improvement came out to be 76 % including 33 %increase in children attendance. However, it should benoted that results presented in table are based on subjectivejudgement of teachers and therefore shouldn’t be inter-preted in absolute terms. A teacher expressing his feelingabout impact of SHIP said, “now children are stoppingtheir parents going to traditional healers for preventingdiseases by explaining how diseases are spread in thevillages”. It is also interesting to note officials from educa-tion departments (other than school teachers) also ex-pressed their satisfaction with the initiative. “we have beenworking with this school for many years, we hadn’t seensuch a rapid change in children’s practices”, said an officialafter attending SHIP session. WASEP as well as teachers in schools realized benifitsresulting from SHIP that were not initially planned for.These benefits included increase in children’s confidence toexpress their views and share their feeling through the useof dramas, role playing, and songs; expression of creativitythrough the use of non-traditional teaching methods suchas posters and art; development of skills for data collectionand analysis from the use of homework assignments andexposure of teachers to alternate methods to engage chil-dren in the learning process.!WASEP through an integrated approach (i.e., water, sani-tation, hygiene education both in communities and schools)managed to significantly improve hygiene status and re-duce diarrhoeal incidence by more than 58 %. However, itis hard to attribute of how much impact was received dueto children involvement.				Significant impact has been achieved as a result of SHIPinitiative, WASEP faces a lot of issues and challengesincluding (1) sustainability of SHIP initiative; (2) barrier intraditional teaching systems; (3) inability to cope with highALIBHAI and AHMAD169 G46!	"#demand; (4) lack of coordination among differentstakeholders; and (5) socio-economic hurdles.Due to resource constraints WASEP usually continuesSHIP activities in partner schools for a maximum two years.Initially, it was thought schoolteachers would be able totake over SHIP activities after withdrawal of WASEP.Follow up visits to some schools suggest that teachers aremore active in promoting and sustaining healthier behav-iours but due to lack of training, and communicationsupport materials are not following the systematic proce-dure to teach a topic to involve children in the process ratherthey are using traditional approaches. Unfortunately, teach-ers generally in the northern Pakistan are more accustomedto traditional teaching methods and affecting changes inteaching methodology and government and private educa-tion policy is beyond the scope of WASEP.In order to improve, WASEP has planned to carry outtraining, in its 2nd phase, for teachers in collaboration withother stakeholders and will make sure that each school getscommunication materials and appropriate manual. Due tosuccess of SHIP, demand of initiating SHIP activities inschools in non-partner villages (i.e., non-WASEP villages)is also growing.Finally there are certain socio-economic hurdles for ad-aptation of certain behaviours: e.g., young children fromplaying bare feet in dirty lands if there are no other safeplaces for them to play around; they cannot wash theirhands with soap due to restrictive family budgets. In one ofthe school during SHIP session, it was observed that a girlin Class V kept her newly bought shoes on her lap, andremoved dust on it by her bare hands even after attendingall SHIP sessions. But it shows how the economic condi-tions affect hygiene behaviour as it may be possible thatleather shoe was purchased for this child for the first timein her life and therefore she wanted to preserve its newness.Similarly, at beginning of SHIP activities, there were nowater tap and latrines in schools, and attempt to reduceopen defecation was not fully successful unless facilitieswere built as a result of WASEP initiative showing that bothhardware and software are equally important for changingbehaviour and for impact.		Significant impact in health and hygiene status was achievedby involving children in the process of behavioural changeat school and community levels. The Child to Child (CtC)approach proved to be very effective in providing opportu-nities to children to use their inherent knowledge and skillsin a way they wanted. This created a great interest amongchildren to participate in all activities. In order to make theprocess sustainable, there is a serious need to include healthtopics in curriculum (i.e., textbooks) based on CtC ap-proach, building capacities of teachers, and taking jointefforts by all stakeholders.	AHMAD, T. and ALIBHAI, K. 2000. “Health and hygieneeducation programme: northern Pakistan”. Water, Sani-tation and Hygiene: Challenges of the Millennium, 26thWEDC Conference, Dhaka, Bangladesh.AHMAD, T. and JINA, L. 2000. “School Heath Interven-tion Programme”, Programme Report, WASEP, AKBPS,Gilgit, Pakistan.DR. KARIM ALIBHAI, Pakistan.DR. TAMEEZ AHMAD, Pakistan.	 0/-G463)G464 	'G46 	(G46/&G460%G46		+G463*G46.G463 	-,G463 10/)))))-)')'0/('('(''('("-,,&,-,,&,-,,),,&,''&,''	

Promotion of healthier behaviours through school children

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Promotion of healthier behaviours through school children

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