Farhana Sultana Research Investigator WASH Research Group Centre for Communicable Diseases

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

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

3. Hand hygiene interventions tested to date Soapy water Tippy taps Super jaboncín Sanitizer Photo credit: www.flickr.com, www.wsp.org, Amy J. Pickering, CARE/Brendan Bannon • Handwashing with different cleaning agents at important key times • Worldwide school-based hand hygiene interventions:

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

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

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

7. Methods • Sample size: 2 urban and 2 rural elementary schools • Study sites: urban Dhaka and rural Mymensingh • Target population: school children aged 5-13 yrs • Study period: May 2011- September 2013

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

9. Handwashing station • Soapy water bottlewithmetalholder • 40L reservoirwithtap • Stand • 16L bucket to collect rinse water

10. Soapy water preparation method

11. Handwashing at recommended key times

12. Coughing and sneezing into upper sleeves

13. Data collection techniques

14. Data collection techniques

15. Data collection techniques

16. Data collection techniques

17. Data collection techniques

18. Data collection techniques • Focus group discussion withteachers and schoolcommitteemembers • Pocket votingexercisewithstudents

19. School physical environment

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

21. Subjective, personal and descriptive norm factors

22. Reported knowledge about disease transmission

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

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

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

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

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

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

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

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

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