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My Clean Little Hands: Applying Social marketing to build a culture of hand washing in children.

This idea aims at instilling the culture of hand washing among children as early as one year when they start understanding so that the habit grows in them as they grow older. This project through promotion of hand washing will contribute to better ECD outcomes by cutting off the constant ingestion of faecal matter by children 0-5 years. It is often difficult for grown-up adult mothers and other caretakers to take up the behavior of hand washing at critical times. The project will encourage caretakers in Uganda to actively train their infants and young children to always keep their hands clean by washing them with water and detergents or or other acceptable cleansing agents at critical times.

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Key findings from focus group discussions and key informant interviews with caretakers, community leaders and government representatives

 


Hopes and Dreams caretakers have for their children:

All the caretakers in the focus groups wished to nurture their children well so that they can are successful and are great life achievers later when grown up into adults.  Through successful children caretakers hoped they could gain more status and recognition within their communities, live happier old age lives and leave legacy behind. The main nurturance the caretakers said are providing to the children zero to five includes encouraging the children to be creative so that they can come up with ideas for making money, fending for their education and health needs, training children to be have healthy practices and acting as role models for the children. Some of the outstanding quotes from the discussions are provided:

  • “I want my child to be creative so that she can come up with ideas for making money and I feel good and proud”, female respondent in Balintuma zone, Kiwatule.
  • “I want my child to grow healthy, does not fall sick and is healthy, their hair is not brown”, respondent in Sebowa zone, Kiwatule
  • “For God to give him knowledge and study, then get a job after but not to finish studying and sit back at home’, female respondent in Kiwologoma village, Kira.
  • “I want my child to be a health educator so that he can guide a lot of people just like the job you are doing”, respondent in Kiwologoma!
  • “I want my child to be a health worker because it is motivating when my child is helping other people in the community”, Balintuma focus group.
 
Perceptions and opinions caretakers have on the proposed My Clean Little Hands project:
All the caretakers were optimistic about the project as they saw it as being important in helping their children grow up washing their hands at all times as a healthy practice.
  • “It is a good project because these children will always know that it is healthy to wash their hands all the time”, focus group discussant said.
Caretakers believe it is good for children to know that every time they touch anything dirty they have to clean their hands by washing them.
 
  • “It is very good because if a child understands that after touching anything dirty, I have to wash my hands, before eating anything, I have to wash my hands, after visiting the toilet, I have to wash my hands, the child grows with the behavior of washing hands”, focus group discussant in Sebowa.
The most critical times for hand washing for children that the caretaker identified are after visiting the toilet, after playing, before and after eating food and in the morning as they wash their faces.

The caretakers are convinced if they actively taught their children to always wash their hands, then the practice could help prevent their children from getting sick of intestinal worms, cholera, dysentery, cough and diarrhoea. In the long run the practice could save parents from spending lots of money on treating their children due to diseases spread through ingestion of dirt.

Perceptions and opinions community leaders and local government representatives have on the proposed project:
  • It is a good idea because it will keep our children healthy and attend schools all the time. More especially when you make the habit interesting like inform of Drama so that it’s interesting to these children.
  • This is a good project because we also emphasize hygiene here in this school through encouraging these children to wash their hands every time they visit the toilet and before they eat the food.
  • This would actually work if we can get support on the facility because right now there are jerry cans of water we put near the class room and the dining room thus it would be of great help if we had a tap and soap.
  • “It’s a great project that I would welcome with both hands but why are you targeting the under fives looking at them as being too young to understand? In my opinion you should target the caregivers and the parents in this case because they are the implementers at the end of the day. What I mean is that the information has to go through the care givers but not directly to these little young children. i.e. the maids because they spend most of the time with these children and also the kindergarten teachers for they play a big role in grooming these children”, health inspector, Kira Town Council. 

How caretakers feel when their children have diarrhoea:
  • “I feel very bad because I have to sleep in the hospital all the time as my husband is taking care of the other children at home all night and the father takes care of the sick child as I go home to rest. Thus, it is really tiresome”, lamented a female respondent
  • “I feel disturbed but I run to the VHT for treatment and she refers when she cannot handle”, reported a respondent. 

 

Feelings related to eliminating diarrhoea in children
  • I would feel good and happy because the child can have diarrhoea and you feel like giving up on him/her.
  • I would feel good because I wouldn’t have to worry any more about my child being sick.
  • I wouldn’t be worried about staying awake all the time taking care of my sick child.
  • It would be good but it is very impossible due to these stages that the child has to go through and have diarrhoea

 

The difference elimination of diarrhoea in children would make in the community
  • The community would be healthy and developmental
  • We would be saving money which is spent on treatment.
  • We would have peace all the time and think of other things to do other than thinking about the sick child.

 

Whom the caretakers turn to when their children are sick:

Most of the caretakers run to village health team (VHT) members within their village as the first health contacts when their children are sick. The VHTs often handle mild cases of sickness and refer the caretakers to clinics for more complicated cases such as severe diarrhoea.  Some caretakers reported going directly to clinics in cases where the sickness is more serious and is affecting the youngest children.

  • “If it a very young child then they refer you directly to the clinic because young children tend to be complicated at times”, explained a respondent.
Not surprising, some of the respondents said they first treat the children from home before taking them to the clinic. They sometimes have some medicine in their houses thus they give the sick child first aid and when the condition worsens then they take the child to the clinic.
How caretakers interact with their children:
All caretakers revealed interacting with their children of age zero to five years. The main activities spent together with the children include:
  • Chatting—asking questions because child have a lot stories to share and questions to ask
  • Housework—as children are always copying how it is done and want to try it out with the caretakers
  • “I get time and sit my children down and counsel them to be hard working, disciplined and good people. Those who are misbehaving, I cane them”, reported a respondent
  • Having fun through singing and playing together
  • “Every morning I sit them down and counsel them, take them to church, and sing in church so that they are religious”, said a respondent
 
How we can implement the project?
  • "We can make the process interesting all together through drama and plays where by these teachers train the children how to wash hands so that they can act it out for their fellow children. Children always want to try out something that their friends are doing (copy cats)", said the health inspector.
 
Who to go through to implement the project.
  • The LC1s because they always call for meetings to address the people on various issues, the VHTs since they know every person in the community, health workers are also important.
  • Also the school teachers would preach the gospel of hand washing very well among the children. 
 
Health concerns for children zero to five:
  • Malaria, stomach pain, accidents due to too much playing, headaches, these children also doze due to a lot of playing and pretend to be sick.(But these days we give them water to calm down). When these children have malaria, they can even soil their uniforms which is too bad and embarrassing to them.
  • These children suffer from Diarrhoea, malaria, cough and flu and injuries because they play a lot. When these children get sick, we take them to the clinic and are given first aid or even we have paracetamol which we give them and later contact their parents to take them home.
 
Challenges faced by children
  • Most of the children do not want to listen especially the boys in P4 and above thus it’s a challenge to us in grooming these children.
  • Also the girls are generally more hygienic than the boys and the children in the lower classes practice hand washing the more than those in upper classes. Even these children keep reminding themselves like “you are from the toilet, have you washed your hands?” which is a good thing.
  • Most of these children don’t have manners right from home thus it’s hard to groom them from here, remember charity begins at home and the parents say that “omwana mukuwadde” so they abandon their children to the teachers when it comes to upbringing of these children.
  • We as a school lack the proper facilities like tap and soap to facilitate the behavior thus we have to improvise and use the jerrycans that you have seen outside.
  • The toilets are strictly for girls alone wheras the boys use the bush nearby which puts the whole community at a risk of diarrhea outbreak.Availability of hand washing facilities
  • We used to have a tap but now we put water in the buckets and this where these children wash their hands from using a cup to draw the water from the buckets. We have two washing areas i.e at the toilets and at the dining area. But we have a challenge of disinfecting our toilets may be if you could help us do something about it.
  • It was once when an NGO visited the school and gave each child a tablet of Dettol soap but it was long ago s maybe that’s why the hygiene is not good.
  • About the soap, we used to put a tablet of soap but by the end of the day it has disappeared so we resorted to mixing the liquid soap into the water.
 
Framing the loss
  • If we missed out on this project then our children would often fall sick and eventually miss lessons which would affect their studies thus it’s a good idea to start this project. Also we feel bad when these children are ill because we are also parents.
  • We cannot afford to have our children fall sick all the time and miss out on lessons which would be the case if this project is not implemented especially in this school.
  • Success: every teacher wants every child to perform well and excel that is why they feel bad when these children have missed lessons.
  • We would miss a lot if this project was not implemented because it is aimed at improving the health of the children since they are the nation’s foundation.

Updates on discussions with village leader of Kiwologoma village in Kira held on Nov 13:

Perceptions and opinions on the hand washing projecg
  • I am buying the idea of the project because it would improve the general hygiene of the community and children would not fall sick like they do these days.

Health concerns in the community.
  • Malaria is still the most common health problem that disturbs the people in the community, even when the mosquito nets were distributed, people do not sleep in them thus the problem.

Who to go through in the community to reach to the people for the hand washing project:
  • The LC1s  are the right people to go through because they they know all the people in their community
  • Also VHTs can do a great job of taking you around the village, house to house because they know what is going on in people’s households. This can be an option because several times we have called for LC1 meetings and the turn up is low so in case the people don’t show up, they can always take you around the village.

What the community would miss if they do not implement the hand washing project:
  • We would miss out on having a hygienic community since it’s a foundation for a clean and developmental country. Actually in this community, children are usually found very dirty and are not taken care of so this would be a good project not to miss.

 Summary of the key findings from the first set of interviews with key informants today--Nov.11, 2014.

Racheal and Josephine  set out to interview the first local council I chairperson in Balintuma village, Kiwatule parish, Nakawa division, Kampala...here are the highlights:

Perceptions and opinions on hand washing project
  • This is a good project and it is going to be successful because it is not only beneficial to the child but to the rest of the family members.
  • This is because even us the old people find it hard to always wash our hands but if it’s a culture instilled in these children then the rest of the family would be influenced.
  • It is also good to go through the parents/ caregivers to teach these children about the benefits of hand washing so that it reduces the disease burden among these children.
  • In this community, I always see children playing in mad and they are dirty yet they just pick food and eat it without washing their hands and they end up getting sick.
 
The key people to go through for the implementation of the project.
  • Through the village meetings that we always call for and talking to the mothers about the campaign, but if this fails, then we can get these mothers from their association’s e.g saving groups, market groups, where they always meet and talk so the messages can be passed on through these meetings.
  • Also through schools because this is where most of these children spend their time than home and also the parents these days are too busy for their children and cannot attend to them for grooming thus schools would be the best places to teach these children how to wash their hands at critical times.
  • Also these children go home and start sharing to everyone how they taught them how to wash their hands and eventually everyone adopts the culture.
 
How would we get to these people?
 
Framing the loss.
  • If we miss out on this project, then this community will continue to suffer the diseases that disturb the children. 
 
The Big Picture


 

Updated write-up: November 10


Summary:


When children learn early in life and develop the necessary skills, hand washing is more likely to become a habit they will practice for the rest of their lives. Most children develop the ability to wash their hands independently by about three years of age. Before that caretakers need to help them wash their hands (or for babies and young toddlers, caretakers need to do it for them). After age three, children will probably still need a bit of help. Teaching children about hand washing early in life is important. Hand washing prevents the spread of diseases which make children sick. Children are ready to learn about hand washing when they are still very young.

The project will use mass media, interpersonal communication and other forms of social marketing in which people will be reached with messages and the hand washing skills. The project will apply implementation research to identify the perceptions and opinions of parents and caretakers have towards—early child development, ingestion of faecal matter by children, training children on hand washing from early stages of life, perceived role models to achieve this, potential threats to the campaign and partners to work with to roll it out.

The target for the project are parents with children below 5 years, teachers at schools, community leaders, older siblings, children 1 to 5 years, etc.  Since infants and young children are copycats they are more likely to learn from others who are seen washing hands and would act as role models in the adoption of the hand washing skills in the long run.

Children do not always take time to wash their hands and often resist parents and caretakers when they are asked to wash their hands before eating, after using the toilet, after touching animals or upon return from playing with their colleagues. Caretakers will almost certainly need to give them lots of encouragement and reminders. Children do not always enjoy washing their hands, partly because it means time out from more exciting things like playing. So the best strategy is to find ways to make hand washing part of the fun, rather than a distraction from their favorite activities. To address this resistance, the project plans to apply fun filled and innovative approaches that are captivating to the children and are embedded into the usual activities they engage in.

To address the challenges around hand washing facilities, the project will identify and use partnerships with established organizations (CSOs, NGOs, FBOs and government) that are supporting provision of such facilities.  The project will also integrate nutrition and stimulation of children within the hand washing intervention. Finally, in order to sustain the intervention, the project will work through government instituted National Sanitation Working Group (NSWG) and its National Handing Washing Steering Committee (NHWSC), ministries of education and health, district local governments, communities and private sector providing sanitation and hygiene services or goods as partners.
 

Introduction

Early child development (ECD) is a critical life event for all humans yet the recent global evidence indicate it is not receiving appropriate attention. ECD is a product of environmental, biological and social factors, which require addressing in an integral manner. This project is one of the first focused on promoting hand washing culture as means of reducing ingestion of dangerous pathogens by infants and young children.

If successfully implemented at scale, the project will contribute to better ECD outcomes by addressing reducing ingestion of microbial pathogen that increase the risk of stunting and anaemia and their associated adverse effects on brain development.  Using a two pronged approach that focuses on children as the primary target and mothers/other caretakers as secondary audience, the project is overcoming the current WASH programmatic limitation of focusing on mainly mothers and caretakers. Children are the ones who are loaded with dangerous pathogens and are ingesting them during play or during feeding. Hence by focusing on them the project expects to reduce ingestion of the pathogens and to create a generation which takes hand washing as an acceptable behaviour.
 

Challenge being addressed and justification

Despite the role of diarrhoea in childhood malnutrition, current evidence points at environmental enteropathy to have more profound effect on early child development.  Exposure to large quantities of faecal matter due to poor sanitation and hygiene practices causes environmental enteropathy that is responsible for stunting and anaemia that eventually impair ECD[1]. Human and animal feet are often contaminated with loads of faecal matter infected with dangerous microbes and pathogens which are deposited in children’s play and feeding environment. Such faecal matter end up in children’s mouths as they play and ingest soil matter.  Whereas cutting this faecal to mouth route in children is difficult given the hyperactivity of children, training mothers and caretakers on hand washing with soap, safe food preparation, heating, cooling, and storage could reduce the risk of environmental enteropathy. This however is insufficient to overcome the challenge of ingestion of faecal matter by children as it is the children who are directly loaded with faecal matter. It is therefore important that in addition to mothers and other caretakers that WASH interventions directly focused on children for own hand washing at critical times.   
Ngure et al. (2014)6 recommended adoption of new technologies especially child play areas as means of reducing ingestion of dangerous pathogens by children. This is scientifically appropriate but at the moment looks impractical socially, economically and culturally inappropriate in African setting. Yet it is also almost impossible to eliminate faecal matter in children’s play and feeding areas.  Promotion of behaviour change interventions for hand washing by children and their caretakers in addition to traditional household WASH behaviour change together with targeted hand washing, hygienic preparation and storage of complementary foods for children seems the most viable approach to reducing ingestion of these pathogens by children. If the behaviour is instilled into children at an early stage of life, the children are more likely to grow into healthy and productive adults with a culture of washing their hands. A vicious cycle of hand washing could easily be created as result of such intervention if it is promoted at scale. Not only will this save lots of resources currently spent on enticing adults who did not grow up washing their hands, but will also create population of adults who grow to their full potential. In addition, it is important to explore the social, economic and cultural acceptability of the concept of safe child play spaces in low income households.

Obtaining perceptions and opinions of the mothers and other caretakers regarding child centred WASH interventions and on how to reduce environmental enteropathy and diarrhoea would be important in designing the hand washing intervention to reduce the interaction between faecal-oral vectors of the child’s hands and the hand-to-mouth activity.

Reference:
[1] Francis M. Ngure,Brianna M. Reid, Jean H. Humphrey,Mduduzi N. Mbuya, Gretel Pelto, and Rebecca J. Stoltzfus.WASH, environmental enteropathy, nutrition and ECD. Ann. N.Y. Acad. Sci. ISSN 0077-8923 pg.118-128
 

Goal:

  • To contribute to the improved early child development outcomes through reduction of morbidity and undernutrition among children below 5 years due to ingestion of faecal matter.
 

Objectives:

  • Assess the perceptions and opinions of parents, grandmothers, teachers, health and community service providers and other community representatives on hand washing and prevention of ingestion of faecal matter by children under 5 years in Central Uganda
  • To promote the culture of hand washing among children below 5 years using mass media, interpersonal communication and other forms of social marketing in Central Uganda
  • To establish and strengthen linkages and partnerships  with existing government, NGO, CSO and community interventions to increase the accessibility of hand washing facilities within Central Uganda
  • To establish cost effectiveness and acceptability of hand washing among children and mothers/caretakers as form of protecting children against ingestion of dangerous microbial pathogens and associated adverse ECD outcomes in Central Uganda.
 

Sustaining the intervention

  • The continued commitment of teachers is essential to the continuation of washing hands encouragement and training of the children also for the parents to be committed in guiding and supervision of these children as the adopt to the behavior.
  • As this behavior is targeting the children when they are young we hope that when they grow older they will teach their young fellows the same practice.
  • Involvement of the private sector such as companies providing detergents is likely to keep the intervention on going even after the end of this project.
  • By integrating the current proposed intervention into ongoing government, development partner, CSO, NGO and community WASH, nutrition and ECD intervention is also likely to enhance its sustainability.
  • Reduced provision of handouts such as detergents and encouraging communities to purchase the items at subsidized rates or to make own items would enhance its sustainability.



Through this project we aim at instilling the culture of washing hands among children as early as  one year when they start understanding so that the habit grows in them as they grow older. We have learnt that it is difficult for grown-ups to take up the behaviour of washing their hands at critical times such as after using the toilet, before eating food, after touching animals, etc.

So with this idea we hope to encourage caretakers to actively train their infants and young childen to always keep their hands clean by washing them with water at critical times! We know that diarrhoeal diseases and environmental enteropathy (a subclinical condition caused by constant fecal-oral contamination and resulting in blunting of intestinal villi and intestinal inflammation) are the most threatening challenges to good growth and development of children zero to five. With increased evidence of how poor hygienic behaviours lead to diarrhoeal diseases and environmental enteropathy, many programs are promoting hand washing among women of reproductive age and adults in order to reduce the burden of these diseases.

However, children are often not looked at when promoting these behaviours yet they are the ones affect and will grow into parents to take care of children. Hence, it is important to encourage adults especially mothers to instill hand washing behaviours into their children in order to kick out diarrhoeal diseases and enteropathy (which is linked with increased stunting in children). Children learn most of the behaviours in early stages of life and mostly from their mothers and caretakers. This project would accelerate the process of creating lasting hand washing behaviour in children and adults since masses would be reached.
 
Approach:
The campaign 'My clean little hands, my health insurance for Life' will use mass media, interpersonal communication and other forms of social marketing that accepted by Ugandan communities. We will apply implementation research to identify the perceptions parents and caretakers have towards training children on hand washing from early stages of life, perceived role models to achieve this, potential threats to the campaign and partners to work with to roll it out.

The campaign will apply fun filled and innovative approaches that are captivating to the children and the caretakers alike. Children often resist parents when they are asked to wash their hands before eating, after using the toilet, after touching animals such as dogs, calves or cats or upon return from playing with their colleagues. Parents also often give up and let the children take the path they wish. Encouraging children to wash their little hands is indeed an insurance for life and is worth all the resources as hand washing is the best way to preventing germs from spreading and keeping children from growing to their full potential or at worst losing their lives. Indeed hand washing is the first line of defence that every smart parent should be proud to inculculate into their children.
Because of the potential resistance from children, we will use strategies that are easy to take up and are doable by all caretakers and children. Children love to have fun and it is this fun that often exposes them to germs and even makes parents prevent them from playing. Our project will thus use fun to promote this intervention.
Why this project will succeed?
We are convinced this project will succeed because it affects every loving and smart caretaker who wants to see their children grow and thrive into the greatest adults. There are already lots of programs focused on addressing diarrhoeal diseases around the world and in Uganda particularly. We will not be starting from scatch and will link up with such initiatives to promote this campaign.
 
Questions for the community
Areas for research through focus group discussions
  • Urban community
  • Rural community
  • School
Questions for the parents/caretakers.
  • What hopes and dreams do you have for your children?
  • How do you interact with your child
  • Who is your role model and for your child?
  • What difference would eliminating diarrhea and enteropathy have in your life?
  • How would you feel if you were able to eliminate diarrhea?
  • What do your children spend doing most of the time?
  • Where do your children spend most of their time??
  • Who do you turn to for help when your child has a health problem?
For the teachers
  • How do you feel when the children are absent due to illnesses?
  • What help do you give to the children when they are ill?
  • What are those common health issues that disturb the children?
  • How would it make a difference in your life if you contributed in reducing these health problems among the children?
  • How would you feel if all the children were able to attend school?
  • As a school, what measures do you have to ensure hygiene of the children
  • Do you have a washing area? 

 

Who will benefit from this idea and where are they located?

All parents and caretakers of children zero to five, and children of this age group in rural and urban parts of Uganda would benefit from this project. this is targeting the children because when the child is still young their minds are fresh and can master what they are told by the caretakers so if the habit of washing hands is instilled in these young children they grow up practicing the behavior.

How could you test this idea in a quick and low-cost way right now?

We would first hold interviews and focus group discussions with parents and caretakers of children zero to five in a selected community in Uganda in order to understand their perceptions and opinions on how to inculcate hand washing into children. This will help us define a strategy to use to implement the campaign. We will then work with role models and media houses to run the campaign in the selected community in order to enhance the practice of parents to train their children to always clean their little hands. Finally, we will actively monitor the campaign to check progress, learn and adapt as means of strategizing for scaling up the intervention.

What kind of help would you need to make your idea real?

We are mainly looking for partnerships to help us plan, implement and monitor the campaign.

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.

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Photo of Tinotenda Dube
Team

This is a very applicable idea. However, where is it that you plan on implementing the proposal. I ask because, there are areas in this world in which clean water is unfortunately still a desire instead of a basic requirement. Hygiene is very important, particularly in developing children, given the correct direction, I don't see why this proposal wouldn't excel

Photo of International Youth Empowerment Network
Team

Thank you Dube for the feedback. We plan to run the campaign in Uganda.

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