Behavior Change Communications (BCC): Hygiene Promotion through Community and Schools Case Study Research Report

But today I can recognize that events back then were part of a life -long pattern in which thinking and doing have either come together or failed to come together I think, I reach a conclusion, I turn the conclusion into a decision, and then discover that acting on the decision is something else entirely, and that doing so may proceed from the decision, but then again it may not. Often enough in my life I have done things I had not decided to do. Something whatever that may be goes into action; ---I dont mean to say that thinking and reaching decisions have no influence on behavior. But behavior does not merely enact whatever has already been thought through and decided. It has its own sources, and is my behavior, quite independently, just as my thoughts are my thoughts, and my decisions my decisions. The Reader, Part I Chapter V Bernhard Schlink ( translated from the German by Carol Brown Janeway)

Contents About the Research Team Acknowledgements Acronyms 1. Introduction and Overview 2. Formative Research, BCC Strategy, and Channel Identification 3. Message/Material Development 4. Design and Implementation of Training 5. Behavioral Change against Project Objectives 6. Behavioral Impact from Integrated BCC Approach 7. Conclusions and Recommendations Annexure Table: Self reported / observed behavior Table: Adoption of new behaviors per site 18 27 39 42 04 05 06 07 09 13 15

About the Research Team Ms. Khalida Ahson, Lead Researcher, is an independent consultant and has worked for USAID, UNDP, Planning & Development Department, Government of the Punjab, Lahore, and Inter/national NGOs e.g. Shirkat Gah-Women Resource Centre. She holds a Masters degree in English Literature from the University of the Punjab, Pakistan. She started her career as a mid-level manager with World Wide Fund for Nature-Pakistan and has held senior management positions with international development agencies and NGOs like UNDP, Indus Resource Centre (IRC), Society for Advancement of Education (SAHE), SDC-Civil Society Human and Institutional Development Program and PLAN. Her particular interest is Human and Institutional Development and Gender Mainstreaming. Ms. Rohina Iqbal, Research Assistant, is working with Association for Gender Awareness and Human Empowerment (AGAHE), as Project Coordinator and Operations Manager. Her responsibilities include capacity building of AGAHE staff / community and monitoring of its programs and projects. Her strengths are her ability to build rapport with the community. She has done her Masters in Sociology from University of the Punjab, Lahore, Pakistan.

Acknowledgements The research team would like to thank everyone in the Islamic Republic of Pakistan who assisted in the case study research and presentation of information included in the final report. We would like to acknowledge the partner NGOs or grantee NGOs, located in the selected target districts for the case study research namely Gujrat-Punjab, Sukkur-Sindh and Rwalakote-Azad Jammu and Kashmir. This includes the partner NGO based in Okara where the case study research tools were pilot tested. The field work could not have been a success without the cooperation, accommodation and hospitality of these partners. It is pertinent to mention that these organizations/key channels received training/orientation and served as a resource for training and behavior change in others. We would like to acknowledge key participants of the Focused Group Discussion, In-depth Interviews and Semi Structured Interviews, critical to the success of the work, with the consideration, that it would be quite impossible to appropriately acknowledge them for the sake of confidentiality. Finally, it is important to recognize that the behavior changes and health effects resulting from the work in Pakistan are attributable to the tireless work of a team of community hygiene promoters committed to improving the health of their communities. The author regrets any errors or omissions.

Acronyms KP FATA AJK BCC BCS TIPs PC CHP SHP CHP SHP HP PPP NGO CBO IRC IRB SSI FGD IDI NA Khyber Pakhtunawa Faderally Administered Tribal Areas Azad Jammu and Kashmir Behavior Change Communications Behavior Change Strategy Trials if Improved Behaviors Project Coordinator Community Hygiene Promotion School Hygiene Promotion Community Hygiene Promoter School Hygiene Promoter Hygiene Promoter Public Private Partnership Non-Government Organization Community based Organization Interactive Resource Center International Research Board Semi-Structured Interview Focused Group Discussion In-depth Interview Not Applicable

1.

INTRODUCTION AND OVERVIEW

1.1. Setting the stage The Pakistan Safe Drinking Water and Hygiene Promotion Project (PSDW-HPP) assists local governments and communities to safely maintain and operate water treatment (purification) systems, as well as to promote good personal and household water hygiene in order to maximize health benefits. The Academy for Educational Development (AED) is primarily responsible for the hygiene promotion component of the project. Under this component, the approach is to target parents of children under five to reach large scale primary audiences with behavior change messages and activities to create sustainable improved hygiene practices. 1.2. Project Scope, Case Study purpose and Project Objectives

The hygiene promotion component of the project aims to assist communities in 28 districts for Community Hygiene Promotion (CHP) and 40 districts for School Hygiene Promotion (SHP) component in Punjab, North West Frontier Province (NWFP), Sindh, Baluchistan including Federally Administered Tribal Areas (FATA) and Azad Jammu and Kashmir (AJK) to promote good personal hygiene and safe drinking water practices in order to maximize health benefits. Case Study Purpose The purpose of this case study is to y Conduct research aimed at gaining insights into the school and community hygiene promotion project components and how they work together in an integrated fashion towards behavior change at the household level. y Gain an understanding of how the program is impacting the communities it serves and those involved with regards to: o Sustainability of the model that is being used i.e. involvement of NGOs, private sector, and key channels, such as mosque Imams, respected women from the community, physicians, etc.); and o Behavioral sustainability within target groups (families mothers and fathers of children under the age of five) as a result of exposure to the Projects behavior change communication approaches and technologies. Project Objectives Objective 1: To Build the Capacity of Partners to Implement the School Hygiene Promotion Program NGOs trained in the school program Teachers trained in the school curriculum Objective 2: To Gain Stakeholder Support for Implementation of the School Program Objective 3: Ten-Week School Curriculum Administered with Students of Grade Four Objective 4: Adoption of Doable Actions Among Students of Grade Four and Sharing of Information with their Families The uptake of following doable actions:

y y y y y y y y

Hand washing with soap before eating Hand washing with soap after toilet Air drying of hands Hand washing with soap of younger siblings hands and air drying Take soap and water to mothers prior to meals Assist mothers with solar heating of water Ask parents to buy soap and also sharing lessons learned related to hygiene with siblings and parents, assisting younger siblings and parents with the above doable actions and taking home calendar (material) to mother.

Objective 5: To Build the Capacity of Partners to Implement the Community Hygiene Promotion Program/Involvement of Key Channels in Promoting Improved Hygiene Behaviors Objective 6: Community Hygiene Program Implemented in Targeted Districts Objective 7: Improved Hygiene Behaviors at the Household Level 1. Improved hand washing behaviors, Hand washing with soap at multiple critical times (self and teaching children to do so), Air drying of hands 2. Hand washing stations set up at the household level (two places), HW station set up near kitchen, HW station set up near latrine, Provision of soap at both locations Objective 8: Improved Hygiene and Safe drinking water Behaviors at the Household Level 1. Adoption of at least one water purification method, Households obtain water from filtration plant, Households appropriately purify water by boiling, Solar filtration 2. Improved water storage at the household level, Drinking water kept in clean, raised, covered containers, Water taken out of container through tap, long-handled scoop, or poured from a narrow-necked container Objective 9: Develop radio spots for airing and use other Mass Media approaches in support of program activities

2. FORMATIVE IDENTIFICATION

RESEARCH,

BCC

STRATEGY

AND

CHANNEL

Experience and research forms the basis of all key behaviors identified for promotion. The projects hygiene promotion activities, led by AED, are based on a formative research. The purpose of this formative research was to understand the attitudes, knowledge, and practices around the priority water, sanitation, and hygiene areas, including: (1) washing hands with soap, (2) storing water safely, (3) purifying water, (4) using filtration plants, and (5) safely disposing of feces. This formative research was conducted during the first week in February 2007 to the first week in March 2007. During the formative research primary data sources1 comprised of mothers and fathers of children under five from households with at least two children under five years old. Secondary data sources comprised primary school girls and boys in class four and Madrassah school, less then ten years of age. Community members, included school head masters, parent/teacher association members, class four primary school teachers, Madrassah school teachers of children less than ten years old, lady health workers (LHWs), and Imams who give Friday sermons in local mosque. Purpose sampling was used to select the primary data sources within each district and site. Selection criteria included households: (1) with at least two children under five years old, (2) in low-income areas, (3) with parents who are primarily skilled laborers, farmers, and housewives, and (4) with parents with less than eight years of education. Convenience sampling was used for all secondary data sources within each location where these sources were found. The formative research was conducted in the following six districts: Lahore, Mansehra/Haripur, LasBela, Thatta, Mohamand Agency, and Muzaffarabad. These districts were selected from the list of 31 districts that the project was tasked to work in. Within each district, two sites were chosen. Sites represented rural and urban audiences and the sample fell within a two-kilometer radius of a government water filtration plant. Based on this initial gathering of behavioral knowns and unknowns, regarding. actual practices, motivators, barriers, the research conclusions and recommendations were drawn to develop a behavior change strategy. The study also resulted in analysis of the above mentioned behaviors and identification of: doable behaviors to promote; specify main intervention areas and its activities; determining the communication and training activities; and specific behavior change communication and training activities. 2.1. A Community Hygiene Promotion Program (CHP) was developed under PSDWHPP behavior change communication strategy. Under this program, the PSDW-HPP identified grantee NGOs in target districts and trained selected staff. The grantee staff comprises a project coordinator (PC) and a team of two (fe/male) hygiene promoters (HP). There are two HPs for each Tehsil and the PC has the overall responsibility of operations and management in the district. The trained staff are responsible to: y Arrange and conduct Mother and fathers group sessions; y Arrange Interactive theater performances in the community; y Arrange Community melas; and

Data sources are research sources of information, those with whom the research is conducted. Data sources and target audiences are not necessarily the same thing, though in some cases they can be. 9

Orient and follow-up key influentials i.e. mosque Imams, women volunteers, physicians, NGOs and CBOs. The CHPs are assisted by the PC in all of the above. The CHP team is mentored and monitored by project staff and consultants. The CHP comprised the following activities: Mother and fathers group sessions Mothers /fathers session are arranged by the HPs hired under the project by Grantee NGOs. During the activity an orientation on key messages of PSDW-HPP is given to 8-10 mothers/fathers with children under five from a specific mohalla (colony) in the field, through a pictorial flip chart. The project criterion to conduct BCC is in specified tehsils where Government of Pakistan has installed or plans to install filtration plants, Union Council is then selected on the bases of where filtration plant is installed in a tehsil. The orientation is conducted by HPs, trained by consultants, whose training was arranged by PSDW-HPP before implementation in the field. The HPs are provided with a Guide to conduct a mothers/fathers session and other resource material, principally a flip chart with appropriate picture illustrations, which is instrumental in conveying the messages to mothers/fathers effectively. Other activities held under the CHP component augment the session e.g. hygiene melas, and community interactive theaters. The mothers/fathers who are a part of the session may attend the melas or the theater if they are held near their mohalla. The fathers are given an identity card holder as keepsake of the session. The mothers and fathers sessions are reinforced through key influential i.e. women volunteers, mosque Imam and physicians. Reinforcement is provided to mothers primarily through women volunteers and physicians and to fathers, through mosque Imams. However, primarily, all key channels are able to reach both mothers and fathers.

Interactive theater performances in the community Under this activity, the grantee NGO staff identified and selected community volunteers to be trained in interactive theater. The PSDW-HPP asked the grantee NGOs to select at least 7 such volunteers from the community in each district, however this varied from district to district. The selected volunteers were trained by the project through Interactive Resource Centre-Lahore (IRC) using one of the 8 scripts developed for the purpose. This was a fiveday training. Eight scripts (15-25 minutes) were developed by IRC catering to relevant primary target audience i.e. mothers, fathers and children. The overall performance takes approximately 1 hour when being performed in front of the community. It is followed by a discussion at the end to clarify issues and answer questions raised by the audience. Community melas 2 Under this activity the grantee partners arrange hygiene melas which are widely publicized in the tehsil. A key influential from the local government set-up and/or bureaucracy is invited to inaugurate the event. The hygiene melas are, if possible, coincided with international days e.g. World Hand Washing day etc. A theater performance is also arranged during the mela. The
2

A traditional, cultural fair popularly organised in Punjab-Sindh provinces to commemorate a religious Sufi leaders death anniversary or celebrate a good crop. The project used this traditional local event to its advanatage 10

partners put up a main stall at the mela where they arrange practical demonstration of hand washing. They also announce different methods of water purification on the sound system for the benefit of people attending the mela. Other NGOs, mostly working in the water, health and education sector, are also invited to put up stalls. There are merry-go-rounds and puppet shows are arranged for children. Media is also invited to the mela. Local community-based organization (CBO) Where a local NGO/CBOs is working in health, hygiene, environment and education sector, in the same district/tehsil, the partner NGO train the NGO/CBOs and also guide them to integrate the key messages of the project in their mainstream activities. Key influentials Mosque Imams: On an average there are 20-25 mosques in a union council. The Imams of these mosques are given a one-day orientation by the CHP with a desk top reminder with key hygiene messages. All the messages in the desk top reminder are augmented by a relevant ayat (excerpt) from the Quran (Muslim Holy book). The desk top reminders are produced in provincial languages. Women volunteers: The CHPs identify active women from the community through mohalla meetings. The criterion to select the woman volunteers is that they be well respected by other women of the community. The women are given an orientation session in which a calendar is handed over to them. They are oriented to give the messages contained in the calendar to other women in their community. Physicians: The CHPs identifiy medical doctors, preferably child specialist and/or doctors working mostly for local women and children. They are given a one-day orientation. The doctors are provided with certificates to give to model mothers, who nurse their child back to health from diarrhea or have been conscientious in their childs health. The HPs follow-up the key channels to get feedback on how the hygiene messages are being adopted by the community.

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2.2. The School Hygiene Promotion Program targets boys and girls from grade 4 government primary schools as message carriers to their mother/families. The school program involves 1.) teacher trainings by school hygiene promoters (SHP) and 2.) a ten-week, interactive hygiene promotion curriculum with fun, take-home exercises that the students participate in and share with their families. The teachers are trained to deliver this curriculum to the students. The PSDW-HPP identified grantee NGOs in target districts and trained selected staff under this component. The grantee staff comprised a project coordinator (PC) and a team of two (fe/male) hygiene promoters / master trainers. There were two master trainers for each Tehsil and the PC has the overall responsibility of operations and management in the district. The PSDW-HPP trained the master trainers. They are mentored and monitored by project staff and consultants. The grantee staff remained active participants in securing the buy-in of the government education officials to conduct the SHP component in the District. After this approval was secured, the master trainers identified: y Government Primary school in the tehsil y Selected primary school teachers teaching grade 4 students y Arrange and conduct Teachers Training The teachers are trained to deliver a ten-week school curriculum comprising 10 activities to students. The master trainers provide follow-up and guidance to the teacher. 2.3. Public-Private Partnership The PSDW-HPP is working in collaboration with private-sector partners, such as Unilever to enhance its reach and impact in schools and communities. Unilever provides soaps, leaflets, posters and experimental germ glow machines. The soaps were distributed through both CHP / SHP component. The germ glow machines demonstrations were conducted in schools. Soap and gifts (pencil box, bandanas) are given to students of grade 4 who had completed the school curriculum. Material was given to schools for display. Under CHP, the partners distributed the material from Unilever at melas and theater performances. 2.4 A Mass Media Campaign complements the Projects behavior change work through the communities and schools, reinforcing messages and activities delivered through CHP/SHP. The PSDW-HPP implemented this program with local FM radio channels. The grantee partners were informed and given the radio spots so that they could air these during their CHP component activities, particularly, melas. The radio spots were developed in 7 regional languages of Pakistan. There is a longer version of 45 seconds and a shorter version of 28 seconds.

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3.

MESSAGE/MATERIAL DEVELOPMENT

A desk review was conducted by the PSDW-HPP during Oct-Dec 2006. This review identified UNICEF as the most active organization in prioritizing and implementing its hygiene communication strategy in Pakistan. However, the approach commonly used by actors and stakeholders in Pakistan for hygiene promotion was didactic and communities mostly were told what to do because it was good for them. An essential feature of PSDW-HPP behavior change strategy is that it views the health problem through a behavioral lens and defines and promotes key behaviors. It fostered a logical, disciplined and consultative method for selecting strategic actions that are most essential for promoting adoption of behaviors needed for the desired health outcome in this instance, reduction in diarrhea disease through preventive measures. The behavior change methodology used in the project fostered behavior change, as opposed to simply increasing peoples knowledge. It was based on an understanding of how families think and behave, the constraints and limitations they encounter, and the reasons they may resist change. The methodology was developed after a process, which required community outreach and broad community participation. It included implementation of trials of improved practices (TIPs). The community participation in the process of materials development was enriching. With regard to graphic materials, it was observed that community prefer illustrations that are detailed, contain less text, and present things they way they should be, as opposed to the way they actually are. For example, family was represented, not as they existed in the community, but as an ideal. The illustration became the model for replication for the target audience. Two types of graphic products were developed, those intended for use by NGOs and those aimed at community. Products for Grantee partners are designed to aid them in interacting with community. These are: 1. NGO Manual: covering the process and use of the materials 2. Teachers Training Manual: designed to aid Master Trainers in delivering the school curriculum containing 10 interactive, fun activities to teachers 3. Flip Chart: depicting ideal behaviors, picturing local characters and settings. Products for community consisted of reminders. These are: 1. Calendar: depicting the action community needs to take to be safe from germs. It was intended to be posted in the home for mothers, fathers, children. 2. Desk top reminder: for mosque Imams consisting reinforcement of hygiene behaviors through Islamic teachings 3. Scripts: theater scripts suited to target audience i.e. mothers, fathers, children 4. Posters: for dissemination/display at filtration plants, schools, CBOs and other venues 5. Danglers: for display in shops to remind target audience to buy soap 6. Certificates: disseminated to best mothers by physicians 7. ID Card Holder: intended as a gift for fathers attending the fathers group session 8. Teachers Manual: designed to aid them in delivering the school curriculum containing 10 interactive, fun activities 9. Students Reminders: calendar mentioned above to take to mothers after completion of 9th activity at the school with teacher

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10. Activity chart: a weekly planner for students to check practice of hygiene behavior at critical times 3.1. Research findings

PSDW-HPP was able to develop attention-grabbing and self-explanatory BCC material i.e. calendars, posters, danglers, flip charts, desktop reminders etc. The BCC material is a huge success. It was appreciated by both grantee NGOs, target audience and key channels, both for CHP and SHP component. The children had particularly enjoyed the school curriculum produced for them. The calendar was a proud possession and the activity chart was filled with enthusiasm. The educational topics were intimately linked to the graphic illustration to encourage people to put the message transmitted into practice. Not only did the project team take considerable care to generate materials in collaboration with the community, they also put forward a similar effort to pre-test them. The purpose of the tests was to avoid incorrect or confusing messages or messages that were inconsistent. The community made suggestions with regard to the language, positions assumed by individuals in pictures, the use of particular colors, and items missing from scenes. There are many models of message testing; the one used PSDWHPP was a measure of audience reaction to the sampling of materials according to variables like understandability, attractiveness and acceptability.

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4.

DESIGN AND IMPLEMENTATION OF TRAINING

More often than not, people are prevented from adopting new behaviors by obstacles that range from lack of necessary technologies or infrastructure (hardware) to personal resistance arising from distrust, disbelief, cultural barriers, fear of innovation, etc. These obstacles have to be specifically addressed. The PSDW-HPP, made an effort for community hygiene promoters to attain a high level of interpersonal and counseling skills, so they could gain the confidence of household members, discuss with them the obstacles that prevent the adoption of new behaviors, and negotiate a household strategy for overcoming the obstacles. These counseling and negotiating skills are indispensable for a BCC strategy to be successful and play a supporting role by creating a garden in which hygiene promotion activities can flourish. The PSDW-HPP initiative to provide NGOs with support in implementing a hygiene project included behavior-change approaches to improve their project interventions through the use of behavior-change communications. The project provided technical assistance in the form of training to the staffs. Three main training genres were implemented to achieve the above as follows: 4.1. Training of Trainers

A series of three-day Training of Trainers were conducted on Behavior Change Communications, at Islamabad prior to the NGO Training. During this workshop Lead Trainers / Technical mentors were prepared to deliver workshops to staffs, hired under the project, in the selected districts. As these trainers were envisaged to provide training to NGOs from all the four provinces of Pakistan and AJK, trainers, adept at speaking the regional languages of Pakistan were selected to attend the training. The first ToT was conducted by Shahnaz Kapadia Rahat, ECI-Islamabad. As a lead consultant, she has taken forward the BCC message in projects that she is working through her Company, e.g. WATSAN (World Bank), Enterprise Development (The Asia Foundation), etc. The training also resulted in the production of Grantees Training Manual, which, three day training was delivered to NGOs, as part of their preparation to implement the project activities. The above mentioned consultant has the experience of working with two AED projects, i.e. PSDW-HPP and Communication for Avian Influenza prevention. For both the Projects, her task was to train trainers, who would take forward the communication message to the community. On the PSDW-HPP, her role was to train national consultants, who then had to train Grantee Partner NGOs under the project. She was not involved with Capacity Building of filtration plant employees, Public-Private Partnership or media components of the project. She mentioned that her overall interaction with the AED coordinators and team (on both projects) has remained very positive and productive, and she was appreciative of the excellent and innovative work that AED has initiated in terms of Behavior Change Communication (BCC). However, she did mention that on both the projects, the trainer training material was received from AED, and even though the contract was to take forward that same material, it did not really work that way. The material required major revision in terms of a more logical ordering, more appropriate examples, and better formatting. At the end of the day, the Consultant ended up spending considerably more time, than was envisaged. A suggestion was that perhaps AED should consider finding local consultants with expertise to adapt given material to suit Pakistani audience.

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4.2.

NGO Workshops

The CHP-NGO workshops aimed to give NGO staffs an understanding of the importance of behavior change and to show them how they could deliver the behavior change activities in their districts, thus bringing about a positive impact on health. The topics included in the NGO workshop comprised key concepts, practical exercises and discussions and mentoring visits were provided from initial period to final stage. The SHP-NGO workshop were designed to create master trainers within the grantee partner. Under this component a Teacher trainer manual was provided to HPs with a Teacher activity Book. The teachers were trained on Teacher Activity Book by HP. Following the teachers training, the lesson plan based Teacher Activity Book was provided to teachers of Grade 4. Under the SHP component also, mentoring visits were provided from initial period to final stage. 4.3. Theater Volunteers Training

A five day training for theater volunteers was also designed. For this purpose Interactive Resource Centre-Lahore was selected. This NGO is well known in Pakistan, to promote street and interactive theater. The IRC also prepared the eight scripts to be used under the community hygiene promotion component of the project. The theater volunteers trained under the interactive theater workshop, led the theater activity in each district. 4.4. Research Findings

During the case study research, it was discovered that the approach used in the above mentioned workshop genres was designed to provide direction, strengthening and refining communications skills and on giving trainees a theoretical framework or philosophy to guide them in implementation, monitoring, and orientation/training under the project components. The CHP/SHP training particularly focused on interpersonal skills that HPs needed to work effectively with families to change their practices/ behaviors. The workshops gave trainees practical experience in implementation of the planned activities. The ToT, Theater and NGO workshops delivered under the project were dynamic, characterized by intensive work and innovative motivational techniques, including involvement of trainees in leading specific exercises. It was envisioned not just as a way to improve the implementing ability of the trainees but mainly to increase the capacity of staffs to apply behavior change communications. Project Consultants/Mentors Feedback The training of trainers of the project consultants proved to be an effective means to not only train the partner NGOs and their staff but also to visit them in the field and provide hands on support to the trainees. An effort was made to include these trainers / field mentors in the case study research. Three trainers / field mentors provided the following feedback:
y

Project did its best and successfully built the capacity of grantee NGOs and their CHP/SHP teams through concentrated trainings/refreshers and mentoring visits by the consultants and managers. However, replacement of projects trained staff with the

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y y y y y

untrained ones remained a weak area throughout the course of this project. More than 90% of grantee NGOs couldnt manage to keep their trained staffers intact with the project which resulted in affecting the quality of implementation. For a project aimed at changing unhygienic behaviors of low income, rural, semiurban and remotely-living communities, one year is a short span of time during which only the foundation stone of behavior change has been laid. Theres a lot left to be done which should be done in the near future without breaking the continuity of activities. Otherwise, all the hard work done so far may go to waste and desired results may not be achieved. The PSDW-HPP activities were focused in specific union councils, whereas they should have covered the whole Tehsil The target of women volunteer should be at least fifty in each union council, as it is an effective channel Lady Health Worker should have been included as a channel The focus of SHP component should not be on grade 4, but on all primary level students to make it more effective Principal / head teacher of the school should be also be provided an orientation or trained while the grade 4 teacher is being prepared to deliver the school curriculum

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5.

BEHAVIORAL CHANGE AGAINST PROJECT OBJECTIVES

The goal of the project is to encourage / promote hygiene behaviors which reduce the prevalence of diarrhea among children under five years of age. These young children are the most susceptible to diarrhea, and the dehydration it causes is life-threatening for them, especially if they are undernourished. The preventive approach used to achieve the goal was a hygiene behavior change communications program focusing on hand washing, water purification and proper handing of drinking water through community and school hygiene promotion activities. The two types of interventions created a synergy that increased impact at the house hold level in a district. Third intervention is media which complements these two activities. The following narrative gives an analysis of outcomes against project objectives and common themes emerging from the implementation. Objective 1: To Build the Capacity of Partners to Implement the School Hygiene Promotion Program NGOs trained in the school program Teachers trained in the school curriculum This comprised training district based NGOs in the school / student activities and curriculum. The NGO staff, thus trained, called Master Trainers, then trained primary level government teachers and assisted the teachers in applying the school curriculum with students of grade 4. The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: SSI / 3 SHP-PC, FGD / 16 S-HPs, Questionnaire, Interview / 3 Consultants = 22. IDI / 8 teachers, FGD / 16 HPs, SSI / 3 SHP-PC, SSI / 2 Head teacher/Principal, Questionnaire, Interview / 3 Consultants = 32 Data Analysis: NGOs were more than adequately trained. AED Training design, delivery, support activities and support follow-up is more than adequate. The training is innovative. The consultants did a good job of delivering it to NGOs and providing follow-up to NGOs. The difficulty and negative aspect of PPP implementation were reported by PC and HPs across districts. As Sukkur partner NGO has made SHP a part of their education program, there will be another cycle of it. This was confirmed by Head Teacher-Government Primary Girls/Boys School, Bridge Colony/Police Colony Sukkur. The SHP implementation in Rawlakote is weak due to not relevant teachers being trained and different schedule of long holidays. The team did not meet the education department representative in Okara-Gujrat. However, program implementation was strong with active adopter NGO teams/ teachers / head teachers. The consultants interviewed, are skeptical, regarding the sustainability of the effort and recommend another cycle of SHP in the districts, in which it has been conducted. The PSDW-HPP could sustain its efforts namely teachers training design and students curriculum through the provincial training institutes for primary teachers existing in all provinces of Pakistan. The relationship established with the Executive District Officer could be utilized to establish a channel with the Education Departments Training Institutes at the provincial level to institutionalize the training design and school curriculum.

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Common Themes 1. Innovation, uniqueness of training design. 2. Excellence of support material 3. Motivation for Change: health benefits and Islamic teaching 4. Barrier: Short Duration of project (6 month project) 5. PPP: difficult, embarrassing and time consuming for NGOs. Data Analysis: Teachers are more than adequately trained in Punjab and Sukkur. The teachers are inspired by the school curriculum as it was enjoyed by children. They did not find it difficult to deliver due to their excellent training and follow-up provided by HPs. The training is innovative. The consultants did a good job of delivery / follow-up of HPs and HPs provided timely / friendly follow-up to teachers. A good rapport was observed between the HPs/head teachers and teachers when the team was introduced to the school during field work. In Punjab the male teacher reported that Activity 8 was difficult for students. In Sindh the teachers reported that memorizing the poem was difficult because it was in Urdu. In Rawlakote the teachers expressed difficulty in doing experiments/activities due to one-room school. They admitted that they did not deliver the school curriculum as guided by the training/ HPs due to one-room, single teacher schools. However there are one-room single teacher schools all over Pakistan, one of which was observed in Punjab, where the teacher had appropriately and conscientiously applied the experiments. The reason for above weakness in Rawlakote was identified by S-HPs as follows: the AEO did not send relevant teachers for training, which was discovered by HPs during follow-up. A rapport was not observed between the HPs and teachers during field work. The consultant recommend that head teacher/principal should also be trained as part of the program. The PSDW-HPP has brought about change at the level of the school in that the schools, teachers and children have made changes at the personal / school level through their exposure to the SHP. PSDW-HPP needs to make an effort to institutionalize the school programme in the provincial training institutes for primary teachers in Punjab, Sindh, Balochistan, FATA, AJK and NWFP. Each province has independent training institutes for training primary teachers. In the opinion of the research consultant individual efforts by teachers / head teachers will not be enough to sustain the excellent school program produced by the project for SHPimplementation. A different strategy to work in mountainous areas could be devised. Common themes 1. Innovation, Uniqueness of training design. 2. Experiential learning for children. 3. Excellence of support material 4. Motivation for Change: health benefits and Islamic teaching 5. Barrier: one-room, single teacher schools (only in Rawlakote) Objective 2: To Gain Stakeholder Support for Implementation of the School Program

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To achieve the above District education official buy-in for school activities was sought. It was ensured that the target schools receive official permission to become a part of the program. The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: SSI / 2 District Education Department Representatives, FGD / 16 HPs, Questionnaire, Interview / 2 Consultants = 20 Data analysis: The SHP-NGO introduced the program to the local education department representative. They implemented the program with the support of the education department at district level. This support extended to securing permission from the concerned department, for the primary fe/male teachers teaching grade 4 in government primary school, to attend the training and then deliver the school curriculum in their respective classes. This was achieved by issuing directives to the schools through Executive District Officer. The respondents reported that they will take the training forward but could not specify how this will be done except for taking help from the local grantee NGO. A parallel plan to institutionalize the school activities in the school academic cycle in a cyclical manner has not been specified by PSDW-HPP. The PSDW-HPPs efforts to gain stakeholders support for SHP implementation was limited to securing permission for training teachers and delivery of school curriculum. It did not specifically seek to sustain the effort, teachers training design and school curriculum. The teachers trained have been given 2 follow-up visits in the six-month life of the project. This is not enough effort for sustainability of the process/outcome. Common Theme 1. Change in personal/school level appearance of schools, teachers and children 2. Sustainability efforts: nascent and random 3. Sustainability process: unclear Objective 3: Ten-Week School Curriculum Administered with Students of Grade Four The school curriculum with 10 activities developed for students of grade 4, was completed in school with relevant activities/experiments. The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: FGD/ 19 female and 20 male students = 49, FGD/ 19 mothers, IDI / 4 mothers, IDI / 8 teachers = 80 Data Analysis: Children learnt about germs and how to be safe from them. Children liked doing the experiments during the delivery of school curriculum of which potato and rice experiments was the most interesting. The change is the uniqueness of school curriculum design. Students really enjoyed doing the experiments. It was different from their other syllabus. Male students in Gujrat and Sukkur reported how they repeated the experiments with siblings/cousins. The mothers are happy that their children are performing actions that that they use to tell them to do e.g. wash hands. The teachers enjoyed delivering the curriculum because it was easy and activity based. The children, where SHP has been implemented, were looking neat and active. All children were shy but gained confidence as the FGD progressed.

20

Children like to do things and the experiential delivery of the 10 activities proved to be a source of retention for them in Okara, Gujrat and Sukkur. The experiments were not done by fe/male teachers in Rawlakote. They delivered the syllabus in a lecture format. Common Themes 1. Experiential and Enjoyable activity for children and teachers 2. Sense of achievement for children and teachers Objective 4: Adoption of Doable Actions Among Students of Grade Four and Sharing of Information with their Families The hygiene curriculum developed for students of grade 4 motivated the uptake of following doable actions: y Hand washing with soap before eating y Hand washing with soap after toilet y Air drying of hands y Hand washing with soap of younger siblings hands and air drying y Take soap and water to mothers prior to meals y Assist mothers with solar heating of water y Ask parents to buy soap y and also sharing lessons learned related to hygiene with siblings and parents, assisting younger siblings and parents with the above doable actions and taking home calendar (Material) to mother. The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: FGD/ 19 female and 20 male students = 49, FGD/ 19 mothers, IDI / 4 mothers, IDI / 8 teachers = 80 Data Analysis: Instead of 1 child responding, the team asked the whole group to respond. All children participated actively in repeating the key messages. The students in Rawlakote also recited the messages but were less confident in rendition and looked at each other for recollection. The children had invented ways to make sure that they were rubbing hands with soap for 20 seconds. In Punjab they read the 1st Kalma (Islamic holy script) twice, counted slowly to 20 in Sindh and Rawlakote. All the students responded that they help siblings. They responded that they helped mother in Solar filtration. They share the project messages with cousins and relatives. They ask elders to buy soap. The calendar and activity chart was described as beautiful and they have both. The activity chart was submitted to male teacher in Sukkur. Fe/male students had it in their bags in Gujrat and Sukkur. This was observed and confirmed. The children in Rawlakote did not remember the activity chart. Teachers corroborated that households/mothers have adopted the key messages as per sharing of students in Gujrat and Sukkur. This was not confirmed by teachers in Rawlakote where this was corroborated by mothers themselves. The mothers liked the calendar because it had nice pictures which motivated them to make their family, like in the pictures. The mothers were appreciative of the gifts their child got from the school. In Gujrat and Sukkur the soap gift became a motivational factor for children to keep soap in their bags. In Rawlakote, the female students had received gifts from the school, whereas the distribution was not done in the male school. The children helped siblings in adoption of hand washing. The children were not helping

21

mother with boiling water. This was considered hazardous for children by mothers. They helped in solar filtration. Mothers were happy by the learning of their children especially regarding adoption of hand washing, which children adopted after the school program. Previously the mothers had to scold them to wash hands. The mothers interviewed during FGD in Rawlakote were adopters while the mother interviewed was a non-adopter. She had not adopted any behavior change. Common themes 1. Adoption of new behavior 2. Sharing of new behavior 3. Pride of Learning and material possession 4. Motivation for Change: health benefits, Islamic teaching, Saving of medical cost Objective 5: To Build the Capacity of Partners to Implement the Community Hygiene Promotion Program/Involvement of Key Channels in Promoting Improved Hygiene Behaviors Under this objective Partner NGOs (grantees) were trained who in turn trained and oriented : y women volunteers y Mosque Imams y Physicians y Operators of Filtration plant y Local NGOs & CBOs y and approached: y Local retailers PSDW-HPP trained local volunteers in Interactive theater and partner NGOs arranged y interactive theater session in communities The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: SSI / 4 Project Coordinators, SSI / 4 Women Volunteer, SSI / 4 Mosque Imams, SSI / 2 Doctors, FGD / 27 mothers, IDI / 4 mothers, FGD / 20 fathers, IDI / 4 fathers, Spot visit/ 2 retailers (Okara/Gujrat), FGD / 13 Theater Volunteers, Questionnaire, Interview / 3 Consultants = 87 Data analysis: The training was adequate for HPs but not for PCs, according to PCs. The attitude, knowledge and delivery of the HPs was admired by target audienc e and key channels. All the channels were effective except doctors, ACCORDING TO PCs and HPs. None of the 31 mothers met during research had visited/received a doctor/certificate. Women volunteers, mosque Imams, melas, theater performances were effective channels. The mela and theater performances did not catch the imagination of the public in Rawlakote as much as in Okara, Gujrat and Sukkur. Only 1 father from Rawlakote out of 7 admitted to attending a health seminar. He remembered the magicians trick from the seminar. None of the 7 mothers from Rawlakote had attended any such activity of the project. This was not the case in Okara, Gujrat and Sukkur where both Mothers/ Fathers had attended at least one such activity. Theater performers termed their training adequate and unique. Only in Okara and Gujrat the range of 8 scripts were being used. Sukkur and Rawlakote were using 1 script only.

22

The shop keepers did not know whether the dangler had been a cause for people to remember to buy soap but they admitted that it was an attractive dangler. There should have been a separate training for PCs with project/office management modules. LHW instead of doctors would have been a more effective channel for message and certificate distribution as they visit community household as part of their mainstream work. They could have delivered the messages and delivered the certificates to best adopter mothers. Also, the Health department at provincial level could have absorbed the CHPwoman volunteers orientation design in the provincial training institutes for LHWs at the Federal/Provincial level. This would sustain the excellent resource design/material produced by the project. The project should have identified the popular local events that mothers (and fathers) from Rawlakote could attend. The IRC or PSDW-HPP should have explained the objective of devising 8 scripts for different target audiences of the project to the CHP-NGOs and Theater volunteers. The method for boiling water for 5 minutes and using clear bottles for Solar filtration needs reinforcement. Tthis is so because a few mothers reported this time incorrectly, however they were corrected by others mothers. Also questions were asked about correct way of Solar filtration in Okara, Gujrat, Sukkur and Rawlakote by both mothers/fathers. The theater volunteers also reported that the community asks them questions about Solar filtration and also terms it un-islamic. This notion needs to be removed. The attraction of getting a free soap did attract the community to melas in Okara, Gujrat and Sukkur but not in Rawlakote. Common Themes 1. Innovation, uniqueness of training design 2. Separate training for PCs on project/office management 3. Adoption of NGO manual in mainstream work of Grantee Partner / CBO 4. Excellence of support material 5. Motivation for Change: health benefits, Islamic teaching, Saving of medical cost 6. PPP embarrassing for NGOs Objective 6: Community Hygiene Program Implemented in Targeted Districts NGO Hygiene Promoters (HP) conduct: y fathers support sessions y mothers support sessions y Interactive theater y Hygiene melas y Women volunteers training & follow-up y Orient & follow up doctors who counsel mothers on hygiene and give certificate to best mothers with children under 5 y Mosque Imams who share hygiene information in sermons/mosques y Filtration plant personnel who distribute invitation cards y CBOs incorporate hygiene messages into their existing work

23

The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: SSI 4 CHP project coordinators, FGDs 24 HPs, FGD 13 Theater volunteers, SSI 4 Women volunteers, SSI 2 doctors, SSI 4 mosque Imams = 51 Data analysis: Program design was deemed unique focusing on involving and engaging the community through interactive activities. Another success was the development of attentiongrabbing and illustrative BCC material i.e. calendars, posters, danglers, flip charts, desktop reminders etc. Projects BCC material was appreciated by all. Grantee NGOs scope of work was also meticulously designed and they were provided with support by the project through quarterly mentoring visits. However both the PCs and HPs lamented the lack of technical knowledge regarding water purification methods under the project . Theater performances/Melas were effective channel in Okara, Gujrat and Sukkur. This is not so for women in Ralakote who do not attend melas/theaters. In the opinion of the local HPs only school functions are occasions which women attend or they go to tombs of historical religious leaders on their death anniversaries in Rawlakote. Melas are an effective channel to disseminate the message to a large audience. Doctors did not prove to be an effective channel. Mosque Imams were a very effective channel as they adopted the work of the project as part of their own duty as the messages corresponded to Islamic teachings. Community mentioned the distance to filtration plant as a hindrance. Frequent power outages are also a hindrance. The technical questions of the community/stakeholders are genuine. The print media in Pakistan does cover the chemical attributes of plastic, arsenic content of boiled water regularly through articles. The community is not unaware and should not be considered simple by development professionals. These aspects should have been covered in the capacity building of NGOs/ key channels. The use of 8 scripts for different target audience should have been made clear to NGOs/ theater volunteers. Popular local events for Rawlakote should have been identified in collaboration with local teams. LHW would have been a more effective channel as they visit community as part of their mainstream work and could have distributed the certificates to best mother upon observed confirmation of required changed behavior in mothers. Very few projects engage mosque Imams, and that also effectively, therefore, when PSDWHPP engaged them, they felt privileged. Furthermore, mosque Imams deem, and rightly so, projects messages are in line with the teachings of Islam regarding hygiene. The mosque Imams were the most effective channel. Provision of appropriate infrastructure is a prerequisite of a behavior change program. The community request to install filtration plant at union council level is genuine. The PSDWHPP may consider taking this up for advocacy with government authorities. Common themes 1. Uniqueness of program design and material 2. Lack of technical knowledge 3. Effective key channels except doctors 4. Interactive theater uniqueness 5. Mela attract large number of people

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6. Appreciation of use of Islamic teachings in project material Objective 7: Improved Hygiene Behaviors at the Household Level 1. Improved hand washing behaviors, Hand washing with soap at multiple critical times (self and teaching children to do so), Air drying of hands 2. Hand washing stations set up at the household level (two places), HW station set up near kitchen, HW station set up near latrine, Provision of soap at both locations The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: FGD 27 mothers, IDI 4 mothers, FGD 20 fathers, IDI 4 fathers, SSI 4 women volunteers, SSI 4 mosque Imams = 63 Data Analysis: All the respondents reported adoption of improved hand washing behaviors i.e. hand washing with soap at multiple critical times (self and teaching children to do so) and air drying of hands. The team observed 1 house per district during FGD with mothers. 1 house per district during IDIs with mothers. 3 houses were observed during IDIs with fathers in Okara, Gujrat and Rawlakote. 3 households were observed during SSI with woman volunteers. This brings the total to 13 houses observed under CHP field work. Two hand washing stations with soap were observed in all the houses near/in kitchen and outside latrine. All the respondents reported that use of soap has increased as previously they use to think that washing hands with soap was enough. Rubbing hands with soap for 20 seconds and not using towel is the behavior change they have adopted. 63 respondents interviewed had reportedly adopted improved hand washing behaviors. 12 households had made the change to having 2 hand washing stations after their exposure to project activities. Common theme 1. Behavior change adopted for the sake of familys health 2. Increase in usage of soap 3. Increase in hand washing stations Objective 8: Improved Hygiene and Safe drinking water Behaviors at the Household Level 1. Adoption of at least one water purification method, Households obtain water from filtration plant, Households appropriately purify water by boiling, Solar filtration 2. Improved water storage at the household level, Drinking water kept in clean, raised, covered containers, Water taken out of container through tap, long-handled scoop, or poured from a narrow-necked container The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: FGD 27 mothers, IDI 4 mothers, FGD 20 fathers, IDI 4 fathers, SSI 4 women volunteers, SSI 4 mosque Imams = 63 Data analysis: The team observed 1 house per district during FGD with mothers. 1 house per district during IDIs with mothers. 3 houses were observed during IDIs with fathers in Okara, Gujrat and Rawlakote. 3 households were observed during SSI with woman volunteers. This brings the total to 13 houses observed, 3 in each district, under CHP field work.

25

The respondents had adopted one water purification method. The 14 mothers in Gujrat said they use to boil water before mothers session but had switched to Solar filtration as it was easy. The 7 and 6 mothers in Sukkur and Rawlakote respectively were using both methods interchangeably. If they had time they boiled water, otherwise they use solar filtration. Water filtration plant was only used if it was near or en route to male members daily routine. The 4 mothers, 4 women volunteers and 4 mosque Imams elaborated the barriers to boiling water as it is time consuming and the community cannot afford boiling water. Solar filtration is cost free and less time consuming. Water storage at household level was observed in 13 houses. This was kept in coolers / fridge in Okara, Gujrat and Sukkur as it was early summer. The water was observed in plastic bottles in houses in Rawlakote. However the 6 mothers during FGD also reported the use of pitcher in Rawlakote. Solar filtration methods should be reinforced as it being popular, carelessness and forgetfulness in behavior is an expectation that cannot be ruled out. Common themes 1. Filtration Plant being used only if it is near or en route to male members daily routine 2. Solar filtration is easy 3. Boiling water is costly and time consuming 4. Water storage is as per projects message Objective 9: Develop radio spots for airing and use other Mass Media approaches in support of program activities y Design and implementation of effect of air radio and other mass media approaches The following Tool / Sources for Cross Reference/ Triangulation were applied to assess the objective: IDI 4 mothers, IDI 4 fathers = 8 Data Analysis: Only one mother in Gujrat had heard the radio spots by PSDW-HPP. She liked the Punjabi language used in the radio spot. She also liked the mother-daughter dialogue used in the spot to convey the message. It is by chance that the team could not meet any respondent who was a radio buff.

26

6. BEHAVIORAL IMPACT FROM INTEGRATED BCC APPROACH The overall approach in the PSDW-HPP was to work directly with NGOs, while providing support through local staff and consultants. The process was carried out in a series of stages. Supporting materials for both hygiene promoters and the target audience were prepared while the promoters received appropriate training. As the PSDW-HPP is nearing/has completed some of its major program activities, it commissioned a case study research. The methodology to produce the case study comprised determining and defining the research questions for data collection to be gathered through participatory research tools i.e. focused group discussions (FGD), in-depth Interviews (IDI) and semi-structured interviews (SSI). The questions were formulated, submitted and finalized in English-Urdu between the period March 09-21, 2009. After a pilot in Okara-Punjab on April 2-3, 2009, the questions, research study methodology and Informed Consent Form were submitted to International Research Board (IRB)-Washington. Following formal approval from IRB on April 16, 2009 the field work was undertaken as follows: Gujrat-Punjab, April 19-24, 2009, Sukker-Sindh, April 27May 02, 2009 and Rawalakote-Azad Jammu Kashmir, May 03-08, 2009. The following table shows the application of research questions per target audience and key channels:
Community Hygiene Promotion Target Audience & Key Channels Okara Gujrat Sukkur FGD Mother 0 14 7 IDI Mother 1 1 1 IDI Father 1 1 1 FGD Father 0 6 8 SSI Woman Volunteer 1 1 1 SSI Mosque Imam 1 1 1 SSI Doctor 1 0 1 FGD Theater Volunteers 1 4 4 SSI Project Coordinator 1 1 1 FGD Hygiene Promoters 2 6 10 School Hygiene Promotion IDI with female teacher 1 1 1 FGD with mothers of students 1 6 8 FGD with female students 0 5 8 IDI with male teacher 1 1 1 FGD with male students 8 8 IDI with mothers of students 1 1 1 SSI with representative of education 0 0 1 department FGD with Hygiene Promoters 1 5 6 Rwalakote 6 1 1 6 1 1 0 4 1 6 1 4 63 1 4 1 1 4 Total 27 4 4 20 4 4 2 13 4 24 4 19 19 4 20 4 2 16

The outcome of the public-private partnership and media campaign were collected through the above FGDs, IDSs and SSI with NGO staff/community during the relevant session. The research questions focus, probe and analysis is as per following table. These were repeated for each target audience (TA) and key channels (KC) for triangulation of findings:
Question Focus Recall Probe The emphasis was to ascertain if TA and KC remembered relevant activity. The emphasis was to ascertain whether TA and KC understood the objective of the activity The emphasis was to ascertain Analysis The TA/KC remembered the relevant activity, including the channel activity e.g. mela, theater, germ glow machine demonstration The TA/KC stated the objective as our health or childrens health TA/KC found the activity adequate. This was

Objective

Adequacy
3

2 females students became a part of this total from the boys school which was co-ed. 27

whether TA and KC found the activity adequate

Retention

Adoption

Behavior (BC)

Change

Motivation for BC

Barriers to BC

Facilitators to BC

The emphasis was to ascertain whether TA and KC remembered the key messages of the activity The emphasis was to ascertain the adoption of key messages learnt during activity The emphasis was to ascertain what was the previous personal practice of the TA and KC The emphasis was to ascertain why the TA & KC chose to change the previous practice The emphasis was to ascertain the barriers they encountered/observed to behavior change The emphasis was to ascertain the facilitators encountered/observed to behavior change

different for Project Coordinators who recommend training with project/office management modules in addition to generic BC training. The TA/KC retained the messages.

The TA/KC were practicing key behaviors. (Next Table) Rubbing hands with soap for 20 seconds, air drying and solar filtration were never practiced before. New learning, which is logical to keep safe from germs and practice hygiene Boiling water is time consuming and costly

Cost of soap is less than medical cost. Solar filtration is easy. Anything is easy, if done for own children.

following tables gives an analysis of adoption against the key behavior that the project was promoting:

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Behavior Change Hand washing with soap for 20 seconds at multiple critical times (self and teaching children to do so) y Air drying of hands y Hand washing stations set up near kitchen/ near latrine with provision of soap Adoption of one water purification method y Households obtain water from filtration plant y or boil/use solar filtration to purify water y Drinking water kept in clean, raised, covered containers y Water taken out of container through tap, long-handled scoop, or poured from a narrow-necked container y

Analysis of adoption These key behaviors were adopted because they were innovative. Hand washing stations were set up because it is easy to remember to wash hands, if you see soap. Soap near/in kitchen is facilitating factor for mothers.

Solar filtration is adopted because it is easy and cost free. Boiling water is time consuming and costly. Filtration plant is used if it is near or en route on male members daily routine.

The use of log handled scoop is a new learning for Rawlakote and has been adopted. It was mentioned by the community. Keeping a pitcher for water storage was also mentioned in Rawlakote only. The weather in Rawlakote was still chilly. In Okara, Gujrat and Sukkur, as it was early summer, use of bottles in fridge or keeping water in cooler had started. The community in Punjab/Sindh only remembered to mention long handled scoop, when prompted. This response may have been different in winters.

5.1.

Major findings

5.1.1. Community Hygiene Promotion The PSDW-HPP promoted hand washing with soap at multiple critical times (self and teaching children to do so), air drying of hands. The corresponding facilitator was hand washing stations set up at the household level at two places; near kitchen and near latrine with provision of soap at both locations. It also promoted adoption of at least one water purification method i.e. boiling for 5 minutes, Solar filtration or households obtain water from filtration plant. It promoted improved water storage at the household level with drinking water kept in clean, raised, covered containers and water taken out of container through tap, long-handled scoop, or poured from a narrow-necked container. The target audience under CHP are: mothers and fathers. The key channels are: NGO Hygiene Promoters, theater volunteers, woman volunteers, mosque Imams and doctors. This includes trained staff of local NGOs and CBOs. The following table illustrates the adoption, facilitators and barriers for the key messages of the project.
Target Audience Mothers Barrier/s for mothers Hand washing Adopted Soap is expensive. Children play with soap Water purification Adopted Difficult to boil and solar filter for large families Plastic bottles get cracked in the sun. Water filtration plant distant Difficult for non/literate working mothers Adopted Water storage Adopted Boiled water kept for cooling can be a cause of accident in small households Facilitator

Projects messages are good for health of all

Fathers

Adopted

Adopted

29

Barrier/s for Fathers

Lack of infrastructure i.e. bathrooms in Rawlakote

No barriers except distance to plant4.

No barriers 5

The adoption reduced cost of medicine

The BCC Objectives were clear to the target audience and key channels. All reported that the objective of the intervention was prevention of diarrhea through good hygiene behaviors. Protection of germs was also mentioned as an objective of the intervention. Interviewees also mentioned protection of children under 5 as an objective. The 31 mothers interviewed through FGDs or IDIs were appreciative, clear about objective and had adopted hand washing with soap at critical times, one method of purifying water and safe practices of water storage and retrieval. Their motivation was the protection of children/family from disease. All the mothers, except in Okara, mentioned the distance of the water filtration plant as a hindrance in access to this safe water. The 24 fathers interviewed through FGDs or IDIs were appreciative, clear about objective and had adopted hand washing with soap at critical times, one method of purifying water and safe practices of water storage and retrieval. Their motivation was the protection of children/family from disease. The fathers in Okara and Punjab were using their ID card holder whereas, the other 2, in Sukkur and Rawalkote did not remember receiving it. All the fathers, except in Okara and Gujrat, mentioned the distance of the water filtration plant as a hindrance in access to safe water. The 24 Hygiene Promoters interviewed were appreciative of their training. Duration of training was deemed short. Another suggestion was that real community should have been used for role-play during training. Also technical/scientific knowledge of the staff should have been improved as they could not answer such questions of the community: why plastic bottles get cracked in the sun, is this water safe? The four (4) project coordinators interviewed including Okara, except Rawlakote, mentioned that their should have been a separate training for them comprising project and office management modules, before the implementation of the program. Three out of four CHP-PCs also mentioned increase in technical knowledge for such question: boiling water increases arsenic content of water. The four (4) project coordinators were appreciative of mentoring help from the project. However, the team found that there was only one mentoring visit to Sukkur through the duration of the project. Nonetheless, the partner deemed it useful. The four (4) women volunteers were appreciative, clear about objective and had adopted hand washing with soap at critical times, one method of purifying water and safe practices of water storage and retrieval. They knew that they were critical in bringing about change in their community. They appreciated the material and follow-up of the project. The material was a proud possession. The thirteen (13) Theater performers were appreciative, clear about objective of the training and partnership and had adopted hand washing with soap at critical times, one method of
4

The methods of water purification are not a problem for fathers as they do not have to perform this function at the household level. 5 The methods of water storage are not a problem for fathers as they do not have to perform this function at the household level. 30

purifying water and safe practices of water storage and retrieval. They knew that they were critical in bringing about change in their community. The mela was identified as a effective channel by both 28 partners staff and 17 key channels. The mosque Imams and doctors were not asked this question. The community in PunjabSindh describes its experience of a mela enthusiastically. They remembered the messages, the theater performance, the gifts given and other activities of the mela. This enthusiasm of the community could not be determined in Rawlakote. Only one father mentioned attending a Health Seminar. He remembered that his children enjoyed the magicians trick. The mothers met during the field work had not attended the mela in Rawlakote. The four (4) mosque Imam were appreciative, clear about objective and had adopted hand washing with soap at critical times, one method of purifying water and safe practices of water storage and retrieval. They knew that they were critical in bringing about change in their community. The team could meet only two doctors, in Okara during pilot, and in Sukkur. Both the doctors were clear about the objectives of the partnership. The doctors mentioned that women are happy when they receive the certificate of best mother. However, none of the 31 mothers met mentioned going to the doctor or receiving certificate in any location. The capacity of 23 channels (women volunteers, mosque Imams, doctors and theater volunteers was built appropriately, and in the opinion of the 24 HPs and 4 PCs, Women Volunteer and Mosque Imams are the most effective channels. Former because of their easy access to and influence over mothers of children under five and the latter because very few projects engage mosque Imams, therefore, when PSDW-HPP engaged them, they felt privileged. Furthermore, mosque Imams deem, and rightly so, that projects messages are in line with the teachings of Islam regarding hygiene. As reported by 24 HPs and 4 PCs, doctors proved to be the least effective channel because majority of doctors engaged by the grantee NGOs are busy in their practice and hardly find time to promote projects messages amongst mothers. However, it is pertinent to mention that, exceptions were reported under the projects regular reporting formats. Hand washing practices: Respondents washed hands at critical times for 20 seconds. Some respondents mentioned time as 20 minutes but in the opinion of the team, saying 20 seconds is a tongue twister, whereas 20 minutes comes to the tongue more easily. Hands were air dried and this was also mentioned as the innovation, new learning by the respondents. Hand washing places: Two places for hand washing were observed/mentioned by all respondents/team. The community did not mention a barrier to the adoption of this behavior but the high cost of soap was mentioned by all respondents. Lack of infrastructure (availability of water, no bathroom) was also mentioned as a barrier. Water purifying practices: Respondents mentioned adoption of boiling or Solar filtration. The barriers mentioned in this regard were large family sizes, for whom boiling and Solar filtration was difficult. The boiling and cooling of water was mentioned as a barrier in Sindh, where temperatures run into 40-50 for 8 months of the year. Lack of clarity was observed regarding the correct methods by the team e.g. questions about diameter of bottles in Punjab, Solar filtration being done in green bottles in one house in Sindh, questions about how to

31

Solar filter water in cloudy weather from Rawlakote. The facility of water filtration plant was being used by the community, if it was near to their abode. Maintenance and use of water storage containers. Appropriate behaviors were observed in the maintenance of water containers and in the way in which water was drawn from the containers. Key channels to promote the above messages have made changes in personal behaviors regarding the above. They also are committed to the health goal of the project. Doctors were identified as a weak channel by the NGO staff and other key channels. It is also pertinent to mention that no mother from the respondents mentioned the receipt of certificate from the doctor. The hygiene promoters could also not arrange for a meeting with such a mother but they did mention that they meet mothers, who mention that the Projects messages were given by the doctor. Obstacles: One of the most significant obstacles to a more hygienic behavior was the poor economic situation of the families/key channels (excluding doctors). It was difficult for them to afford material (gas, fuel wood) for boiling, adequate water boiling/storage containers and other items, such as soap. The following table gives an analysis of similar findings:
Similar Findings Recall Objectiv e Adequa cy Retentio n Adoptio n Behavio r Change (BC) More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious Motivati on for BC New learning to improve our health Barriers to BC Facilitat ors to BC Health gain/ SODIS

31 Mother

Health

Boiling water is time consumi ng and costly

24 Father

Safe from diarrhea / germs = health

New learning to improve our health

Distance to filtration plant

Health gain and medicin e/doctor fee saving

4 Woman Voluntee r

Health

New learning to improve our health

Boiling water is time consumi ng and costly

SODIS

4 Mosque Imam

Health

New learning to

Econom ic conditio

Practici ng Islamic

32

2 Doctor

Provide health through doctors

about correct way of H/W and air drying N/A

improve our health

ns

teaching

13 Theater Voluntee rs

Give health message to commun ity thru theater

4 Project Coordin ator

Local NGO

Separate training on project/ office manage ment

24 Hygiene Promote rs

Provide skills for commun ity work

More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying

New learning to improve our health New learning to improve our health

Commu nity are unaware and lazy

Raise awarene ss

Boiling water is time consumi ng and costly

Humoro us /enjoyab le scripts to give message

New learning to improve our health

Commu nity beliefs

Excellen t generic BC training, selectio n of effective channels Local commun ity channels / Excellen t generic BC training

New learning to improve our health

Boiling water is time consumi ng and costly; Commu nity beliefs

5.1.2. School Hygiene Promotion The SHP promoted uptake of doable actions by students through delivery of school curriculum by teachers. The SHP component was determined to be weak in Rawlakote. The female teacher reported that she could not do the experiments effectively due to the one room school which had no other facility except student benches. The male teacher delivered the messages as a lecture and did not do any activity/experiment because he also reported that a one-room school and absence of assistant teacher hindered syllabus application. (On the other hand, the male teacher in Punjab also had a one-room school, but had applied the syllabus with classes 2-5. His proud claim was that only the very young students in his class may forget some of the messages, if interviewed but all the other students were learners/practitioners.) Other weaknesses were reported by hygiene promoters. A HP reported that one teacher had given all the calendars to the children without starting delivery. The students in boys school did not remember the correct time of washing hands. The IDI with mother revealed that she had not adopted keeping soap in two places, any water purification method and was taking water out

33

of pitcher with a glass. Unilever gifts had not been distributed in the boys school visited. The reasons identified for these weakness were that the education department did not send relevant teachers for the training. This was discovered during follow-up by HPs. Also, onset of long holidays in December and closure of school till March effected the proper follow-up and distribution of gifts. Follow-up of more than 2-3 schools per day in a mountainous region is not possible. It was an unrealistic target for a 6 month project. The actions and findings are as follows:
# 1 2 3 4 5 Action Hand washing with soap before eating Hand washing with after toilet Air drying of hands Hand washing with of younger siblings hands and air drying Take soap and water to mothers prior to meals Findings The respondents were practicing The respondents were practicing The respondents were practicing The respondents were practicing This was not mentioned as a convincing behavior but the respondents did mention that they helped mothers The respondents do ask for soap from parents The respondents were practicing if mother was solar heating. Where the mother was boiling, the respondents did not help The calendar is serving its purpose and is a proud possession of/for the whole family Water purification Difficult to boil and Solar filter for large families Plastic bottles get cracked in the sun. Water filtration plant distant Water storage Boiled water kept for cooling can be a cause of accident in small households Facilitator Projects messages are good for health of all

6 7

Ask parents to buy soap Assist mothers with solar heating of water

Taking home calendar to mother

Target Audience Barrier/s for mothers

Hand washing Soap is expensive. Children play with soap

The 19/20 fe/male students questioned under SHP were not asked the objective of their syllabus directly but all seemed to be clear that cleanliness of hands is important and necessary to protect from germs. They are practicing and promoting hand washing in siblings, however, their assertion that they help mother in hand washing did not seem convincing. They were very appreciative of the syllabus. The 4/4 fe/male teachers were appreciative of the training. In Okara, Gujrat and Sukkur, the teachers had conscientiously delivered the school curriculum, but this was not the case in Rawlakote. The teachers reported barrier was one-room / one-teacher schools in Rawlakote. However this was not mentioned as a barrier in Punjab and Sindh. They knew that the objective of involving them was to access households through students. They also mentioned protection of children from diarrhea as an objective. The 22 mothers were appreciative of their childrens learning and had adopted hand washing with soap at critical times, one method of purifying water and safe practices of water storage and retrieval. They appreciated the material and gifts given to children. In both Punjab and Sindh the SHPs reported that the gift distribution of soap had instilled the habit of keeping

34

soap in school bag in the children. The team met only one non-adopter mother under the SHP component in Rawlakote. Her decision to not change stems from the belief that old practices are time-tested. Key channels: the key channels for this component were hygiene promoters/master trainers and teachers. Both 16 hygiene promoters and 8 teachers had adopted the key messages of the project. However non-availability of appropriate infrastructure within schools was mentioned/observed. These included lack of toilets, running water within schools. In Rawlakote lack of initiative for both appropriate conduct of experiments/activities for the curriculum and sustainability of the effort was observed. The following table gives an analysis of similar findings:
TA/KC Recall Objecti ve Adequa cy Retenti on Adoptio n Behavio r Change (BC) More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious about correct way of H/W and air drying More conscien tious Motivat ion for BC New learning Barrier s to BC Facilita tors to BC SODIS

4 female teacher

Train children /commu nity through teachers

22 mothers of student s

Teach children

New learning

19 female student s

Keep safe from germs

New learning

Boiling water is time consumi ng and costly Commu nity beliefs Boiling water is time consumi ng and costly Commu nity beliefs NA

SODIS

NA

4 male teacher

Train children /commu nity through teachers

New learning

20 male student s

Keep safe from

New learning

Boiling water is time consumi ng and costly Commu nity beliefs NA

SODIS

NA

35

germs

1 non adopter mother of student 16 Hygiene Promot ers

Not Applica ble (NA) Provide skills for school work

about correct way of H/W and air drying NA

NA

Previous Practice

NA

More conscien tious about correct way of H/W and air drying

New learning

Boiling water is time consumi ng and costly Commu nity beliefs

SODIS

5.1.3. Public Private Partnership Major findings regarding the public private partnership were negative as detailed by 24 HPs, 4 PCs (CHP), 2 teachers and 16 S-HPs interviewed. The only positive aspect reported by them was that as it was a freebie, it caught the imagination of public. Only 1 PC and teacher mentioned the positive aspects of the germ glow machines. The 2 other teachers did not mention its importance and impact but said that it was a good game for children. All of the community respondents (fe/male students and mothers) reported the receipt of soap, as a positive gift. The students had adopted the habit of keeping soap in their bags after receipt of the gift and the mother corroborated this behavior. The major findings were as follows:
y

There were a lot of delays in the shipment of material and the partners had to devote time and effort for follow-up with Unilever to receive their material in time for a particular activity. This resulted in wastage of time and extra work for partners. It is pertinent to mention that SHP was a six month project component. The germ glow machines did not specify handle with care or fragile due to which the courier company did not handle them with attention. Most did not work when taken out of the packing box. These were fixed by partners on their own with PSDWHPP/ Unilever support. A lot of resources and time were thus wasted. The PSDW-HPP had been very strict about not promoting names of soap and insisted with the partners that they should promote the message that any soap can kill germs if the suds are produced for 20 seconds. The posters sent had the following message in Urdu to kill germs, it is necessary to use quality soap life buoy. The leaflets also contained the same message. The above message created a problem for the partners as in the beginning of the project when community thought they were soap-sellers, partners insisted that they were not promoting any soap. After this mass distribution their reputation was tainted and the community started saying to them that dont you see, we knew all along that you were from life buoy. Their image was tainted and are still known as life buoy sellers. The projects name i.e. Pakistan safe drinking water project was forgotten by the target community.

36

It is known to Pakistani public that original red life buoy soap does not produce suds. It also uses a color due to which hands and water become red. By using the red life buoy to promote use of soap in the community, the PSDW-HPP contradicted another important message that suds kill germs. The PSDW-HPP should have guided the Unilever to send quality soaps which produce suds. This low quality soap also created problems for the partners. Germ glow machine demonstration was considered a farce by the community. The PC-SHP were given an orientation after the memorandum of understanding was signed with Unilever by PSDW-HPP. During the orientation a different germ glow machine was used for demonstration than the one sent to the partners. Machines were not working when they arrived in the field due to the fact that the courier company was not instructed to handle with care and/or fragile cargo. The NGO had to employ an electrician to make the machines work. The germ glow machines were low quality and usually the teachers reaction was that aidee wi pagal banan di lore nahin [dont think we are so stupid.] Most science teachers knew that fluorescent powder shines and they embarrassed the team during the demonstration. Unilever training guided that it would take 40 minutes to show a demonstration but it took 1 hour in each school. During the orientation the partners were informed and given written instruction about the 11th activity to be conducted with the partner schools, in addition to the 10 activities contained in the curriculum. This 11th activity was translated and shared with the teachers. It specified that good hygiene practicing students will be gifted with badges, bandanas and lunch/pencil boxes. The preceding items never arrived under the partnership. Children were only given soap and pencil box. Also the pencil box was of low quality. The teachers who knew about this 11th activity got angry with the SHP staff saying that HPs have pocketed the money of the other gifts or have kept the items with them and given them low quality things only. This created image and reputation problems for the partner. The partners were not informed about the distribution criterion at the time of the orientation. When they received the material under the component, they were informed that the material should be distributed as per the following criterion: piped water, wash basin and boundary wall available in the school. The criterion was not based on items which were the responsibility of partners and/or PSDW-HPPs own focus. The question is: what about the children of a school where there is no boundary wall but the teacher/students have produced excellent results? The teacher/students cannot be penalized for not meeting the above criterion. The criterion should have been adoption of critical behaviors by students. The PSDW-HPP was not working for the provision of above mentioned criterion with the district government. This criterion was not in the control of teachers-students who were the main target audience and key channel. Wall charting was started by Unilever to promote life buoy during the same time as material was received from them for distribution. This created an erroneous impression in the minds of the community/school authority that the partners were in cohorts with life buoy and were soap walas. It should have been a part of memorandum of understanding with Unilever that it would not initiate a promotional activity at the same time, in the districts where it was working with PSDW-HPP. The soaps were not distributed to all communities under the target areas. This created problems for the staff as news from small villages travels fast and the communities which were not given soap, chastised the project staff whenever they met them. The soap distribution created extra work for SHP, which was a six month project. 37

The items for childrens gifts were of low quality, especially bandanas. The bandanas were made of cotton bands in the beginning but were later replaced by paper bands stapled together. As the students would try to fix them on their heads, the staple/pin holding the bandana would come off. The use of sharp material to make things intended for children is not recommended. Also the change in material created an image problem for HPs as the teacher thought they were corrupt and mishandling the funds. As most schools have children from class 1-5 sitting together, gift distribution to some children created complex situation for HPs as it was hard to explain to a child of class 3 why s/he could not be given a gift.

5.1.4. Mass Media It is by chance that the respondents met during the field survey had not heard the radio spots produced by the project, being aired by local FM channels. Only one mother mentioned that she had heard a radio spot once and had liked the content, style and language of presentation. The shop keepers met during the field survey did not mention that they noticed whether any consumer looked at the dangler and remembered to buy soap. However they did say that it is an attractive dangler and consumers must look at it.

38

7.

CONCLUSIONS AND RECOMMENDATIONS

The results of the research are encouraging in that they show positive changes in the number of respondents practicing hygiene behaviors do appear to be related to the specific activities of the project. Major conclusions drawn from the respondents are:
y y y y y y

A decrease in diarrheal prevalence (six-month recall) occurred for children. An increase in hand washing of primary caregiver after defecation is reported An increase of hand washing of children after defecation and before the child ate is reported An increase in the presence of a permanent, designated hand washing location is reported An increase in use of soap for hand washing is reported Improvements are also reported in hand washing technique for 20 seconds and air drying of hands.

The determination, dedication, and motivation of community hygiene promoters and theater volunteers stood them in good stead. In addition, the tasks that they were being asked to do were feasible and they were well accepted by the communities. The hygiene promoters had attained a good understanding of the hygiene message and content that they were responsible for communicating. They demonstrated extremely fine interpersonal relationships and were obviously trusted and well-received by households. However, the negotiating aspect of their counseling needed improvement in Rawlakote. The team in Rawlakote exhibited a tendency to do rather than negotiate and decide what should be done before exploring the situation in greater depth with the households. This could probably be because of pressure from the project. 6.1.
y

Process Results NGOs / Coordinators / Hygiene promoters increased their skills in management of groups, behavior observation, Trials for Improved Behaviors (TIPs), qualitative analysis of obstacles, development of strategies to address obstacles, testing of strategies, preparation of materials, and organization of a community launching activity. They also received practical training in behavior change communications The project was able to strengthen capacity for implementing Behavior Change as individuals from districts all over Pakistan received training in the use of materials and in implementing and planning hygiene behavior change programs. Some of these organizations had been involved from the initiation period of the project. These main behavior change partner organizations are trained and can be called/used as trainers, with the ability to transfer the behavior change approach to other groups. In addition, these organizations are committed to make behavior change an integral component of their programs. Institutional partnerships were forged through innovative activities e.g. theater/melas that enriched the approach and assisted in dissemination.

39

Partners strengthened their inter-institutional links and ties. The ground has thus been prepared for institutionalizing a network of behavior change communications promoters. The project was able to document a Hygiene Behavior Change Approach. Materials used in the project were refined and produced and made available to a number of organizations and are now being used in their programs. The project carried on activities outside the health/hygiene sector through training teachers and implementers to apply principles of behavior change in government primary schools through creating a special curriculum for use in the schools. This resulted in implementation of the Behavior Change Strategy in Schools. Hygiene results

6.2.
y

The desired hygiene effect from behavior-change interventions is a reduction in diarrhea prevalence. During the survey respondents were asked about diarrhea prevalence within the past six months for all children. All of the respondents reported decrease in diarrhea incidence. While this decrease may be attributable to the program interventions, it could possibly also reflect seasonal variation as the case study research was conducted right after the winter season in Pakistan. Behavior change results

6.3.
y

The survey is suggestive of improvements in health and positive changes in behavior especially hand washing behaviors. These improvements should be viewed as resulting from a well designed behavior change program. As a result of capacity-building training, and dissemination of materials, behavior change approaches are being used in most provinces of Pakistan. Recommendations

6.4.
y

The Lady Health Workers are identified as a key channel by NGO staff, consultants and the community. It is argued that they could have improved the outreach of CHP as they are better placed within the community. The criterion to distribute gifts through public private partnership, under the SHP should have matched the program objectives. If the project was working for availability of infrastructure under the school hygiene promotion, then it may have had this criterion for distribution of gifts under the public-private partnership to schools. The criterion should have encompassed adoption of key messages by students. The counsels by partners regarding public private partnership are genuine and should be judiciously taken up by PSDW-HPP. It is important to emphasize that a more clear and detailed memorandum of understanding could be developed for all such future initiatives.

40

The organizations /consultants that participated in training have developed interorganizational/personal links, and the trained staff/consultants have formed ties among themselves. These links and ties have created a nascent behavior change communication network. This network needs to be made sustainable. A plan for making it so, is needed. The challenge for PSDW-HPP is how to build on what has been achieved so that the enthusiasm and interest do not dissipate. Some coordinating mechanism is needed. PSDW-HP is well qualified to play the role of coordinator for such an initiative and network. A website needs to be created and maintained so that electronic communication is possible among trained behavior change consultants/staff and organizations. The training material of the project under CHP and SHP should be institutionalized with the government training institutes affiliated with the health and education department in all provinces. This will guarantee its continued usage and application.

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Self Reported / Observed Behavior Community Hygiene Promotion Component

Target Audience/ Key Channels Total Adoption of Hand washing with soap at multiple critical times (self and teaching children to do so) Air drying of hands Hand washing stations set up near kitchen/ near latrine with provision of soap 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % BC Adoption of one water purification method Households obtain water from filtration plant or boil/use solar filtration to purify water 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % BC Adoption of Drinking water kept in clean, raised, covered containers Water taken out of container through tap, long-handled scoop, or poured from a narrow-necked container 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % BC

Mother Mother Father Father Woman Volunteer Mosque Imam Doctor Theater Volunteers Project Coordinator Hygiene Promoters

27 4 4 20 4 4 2 13 4 24

Self reported Self reported & Observed Self reported & Observed Self reported Self reported & Observed Self reported Self reported Self reported Self reported Self reported

Self reported Self reported & Observed Self reported & Observed Self reported Self reported & Observed Self reported Self reported Self reported Self reported Self reported

Self reported Self reported &Observed Self reported Observed Self reported Self reported Observed Self reported Self reported Self reported Self reported Self reported

42

School Hygiene Promotion Component

Target Audience/ Key Channels IDI with female teacher FGD with mothers of students FGD with female students IDI with male teacher FGD with male students IDI with students of mother SSI with representati ve of education department FGD with Hygiene Promoters Total Adoption of HW w/soap: before eating after toilet help family wash hands and air drying 100 % BC Adoption of Take soap and water to mothers prior to meals Assist mothers with solar heating of water NA6 but purify and store water as per message 94.7 % BC Adoption of Ask parents to buy soap Taking home calendar to mother NA BC

Self reported

Self reported

Self reported

19

94.7 %

Self reported

Self reported

94.7 %

Self reported

19

100 %

Self reported

100 %

Self reported

100 %

Self reported

100 %

Self reported

NA purify and store water as per message 100 %

Self reported

NA

Self reported

20

100 %

Self reported

Self reported

100 %

Self reported

100 %

NA

Self reported & Observed two H/W stations N/A

100 %

Self reported

100 %

Self reported Calendar Observed N/A

N/A

N/A

NA

16

100 %

Self reported

NA purify and store water as per message

NA

100 %

NA

Not Applicable as the question was not askxed from this particular respondent. 43

Adoption Of New Behaviors Per Site

Tool SSI FGD IDI IDI SSI FGD FGD FGD FGD IDI IDI FGD FGD IDI FGD IDI SSI SSI Number Target / 1 PC-CHP 10 Mothers 1 Mother 1 Father 1 Mosque Imam 4 Non-Adopter Mother 6 Fathers 4 Theater volunteers 8 Community Hygiene Promoters 1 woman Volunteer 1 female teacher 6 mothers 5 female students 1 male teacher 8 male students 1 mother 6 School Hygiene Promoters 1 PC-SHP Date 20-04-09 20-04-09 20-04-09 20-04-09 20-04-09 21-04-09 21-04-09 21-04-09 21-04-09 21-04-09 22-04-09 22-04-09 22-04-09 22-04-09 23-04-09 Gujrat /Reported New Behavior The PC had adopted the correct way of washing hands and not using towel. The mothers had adopted the correct way of washing hands, not using towel and solar filtration of water. The mother had adopted the correct way of washing hands, not using towel and solar filtration of water. The father had adopted the correct way of washing hands, not using towel and solar filtration of water. He had also erected a new wash basin outside his bathroom. He fetched water from the filtration plant. The mosque Imam had adopted the correct way of washing hands, not using towel and solar filtration of water. The women had adopted the correct way of washing hands, not using towel and boiling of water. The men had adopted the correct way of washing hands, not using towel and were all teaching their family . one fetched water from the filtration plant. The rest complained about the distance to FP and frequent power outages. The theater volunteers had adopted the correct way of washing hands, not using towel and solar filtration of water. One fetched water from filtration plant. The HPs had adopted the correct way of washing hands, not using towel and solar filtration of water. One fetched water from filtration plant. The WV had adopted the correct way of washing hands and not using towel. The teacher had adopted the correct way of washing hands and not using towel. The mothers had adopted the correct way of washing hands, not using towel and solar filtration of water. The students had adopted the correct way of washing hands, not using towel and helping siblings. They tell friends and family about their new learning. The teacher had adopted the correct way of washing hands, not using towel and solar filtration of water. The students had adopted the correct way of washing hands, not using towel and helping siblings. They help mothers in solar filtration. They tell friends and family about their new learning. The mother had adopted the correct way of washing hands and not using towel. The HPs had adopted the correct way of washing hands and not using towel. The PC had adopted the correct way of washing hands and not using towel.

24-04-09 24-04-09

44

Tool SSI SSI IDI SSI SSI FGD IDI FGD FGD FGD IDI FGD FGD IDI FGD IDI FGD

Target / Number 1 PC-CHP Mosque Imam Father doctor women volunteer 6 mothers mother Father 10 Hygiene Promoter 4 Theater Volunteers 1 Female teacher 8 mothers 8 female students male teacher 8 male students Mother 6 School Hygiene Promoters

Date 28-04-09 28-04-09 28-04-09 28-04-09 28-04-09 28-04-09 28-04-09 28-04-09 29-04-09 29-04-09 30-04-09 30-04-09 30-04 09 30-04-09 30-04-09 30-04-09 01-05-09

Sukker / Reported New Behavior The PC had adopted the correct way of washing hands and not using towel. The mosque Imam had adopted the correct way of washing hands, not using towel and solar filtration of water. The father had adopted the correct way of washing hands, not using towel and solar filtration of water. He was also teaching his children the correct way of washing hands. His children were sharing new learning with friends and family. The doctor wrote on his prescription the correct way of solar filtration for mother whose child had diarrhea. The WV had adopted the correct way of washing hands and not using towel. The women do not nag husbands to bring water from the filtration plant any more but use solar filtration. They had adopted the correct way of washing hands and not using towel. The woman had adopted the correct way of washing hands and not using towel. The fathers had adopted the correct way of washing hands, not using towel and solar filtration of water. They were also teaching children the correct way of washing hands. The HPs had adopted the correct way of washing hands and not using towel. The TVs had adopted the correct way of washing hands and not using towel. The teacher had adopted the correct way of washing hands and not using towel. The mothers had adopted the correct way of washing hands, not using towel and solar filtration of water. The students had adopted the correct way of washing hands, not using towel and helping siblings. They help mothers in solar filtration. They tell friends and family about their new learning. The teacher had adopted the correct way of washing hands and not using towel. The students had adopted the correct way of washing hands, not using towel and helping siblings. They help mothers in solar filtration. They tell friends and family about their new learning. The mother had adopted the correct way of washing hands and not using towel. Solar filtration was being done in green bottles. This was clarified to the mother. The HPs had adopted the correct way of washing hands and not using towel.

45

Tool FGD IDI IDI FGD SSI IDI FGD SSI FGD IDI FGD FGD IDI IDI FGD FGD

Target / Number 9 Mothers Mother Father 6 Hygiene Promoters-CHP Project Coordinator Woman volunteer 4 Theater Volunteers Mosque Imam 6 fathers female teacher 4 mothers 4 female students Mother Male teacher 2 female/ 4 male students School Hygiene Promoters

Date 04-05-09 04-05-09 04-05-09 04-05-09 05-05-09 05-05-09 05-05-09 05-05-09 06-05-09 06-05-09 06-05-09 06-05-09 06-05-09 06-05-09 06-05-09 07-05-09

Rawlakote / Reported New Behavior The mothers had adopted the correct way of washing hands, not using towel and solar filtration of water. The mother had adopted the correct way of washing hands, not using towel and her elder child had become very conscientious about ensuring that his younger siblings wash hands properly. She was using filter by Accessor company. The father had adopted the correct way of washing hands, not using towel and solar filtration of water. He had also erected a new wash basin outside his bathroom. The HPs had adopted the correct way of washing hands, not using towel and solar filtration of water. One HP was using filter by Accessor company. The PC had adopted the correct way of washing hands, not using towel and solar filtration of water. The WV had adopted the correct way of washing hands, not using towel and solar filtration of water. The TVs had adopted the correct way of washing hands, not using towel and solar filtration of water. The mosque Imam had adopted the correct way of washing hands, not using towel and solar filtration of water. The fathers had adopted the correct way of washing hands, not using towel and solar filtration of water. 1 father was fetching water from filtration plant. The teacher had adopted the correct way of washing hands, not using towel and solar filtration of water. The mothers had adopted the correct way of washing hands, not using towel and solar filtration of water. The students had adopted the correct way of washing hands, not using towel and helping siblings. They help mothers in solar filtration. They tell friends and family about their new learning. The mother had not adopted any change. The teacher had adopted the correct way of washing hands (30 seconds) and not using towel. The students had adopted the correct way of washing hands (30 seconds), not using towel and helping siblings. They help mothers in solar filtration. They tell friends and family about their new learning. The HPs had adopted the correct way of washing hands, not using towel and solar filtration of water.

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