Intervention to Promote Hygiene Behavior Among School Children
Intervention to Promote Hygiene Behavior Among School Children
Background: Poor personal hygiene and inadequate sanitation practices among young children in
 Low Middle Income Countries such as Pakistan can lead to critical, life-threatening illnesses
 such as respiratory infections, diarrheal disease, malnutrition and developmental delays. An
 intervention for personal/environmental hygiene practices for primary schoolchildren will be
 implemented at schools in urban squatter settlements of Karachi, Pakistan, aiming to improve
 the hygiene knowledge and practices (K&P) amongst primary schoolchildren and their mothers
 (participants), while identifying facilitating and impeding factors in the adoption of
 hygiene practices for children.

 Methods: The study will be built on quasi-experimental design with mixed methods data
 collection approaches. To assess primary grade children and their mothers' hygiene-status,
 K&P survey will be held in the pre-intervention phase. This phase also includes qualitative
 exploration of mothers' and teachers' perceptions about children's hygiene literacy, factors
 facilitating and impeding the adoption of the same among school children, for which in-depth
 guides and focus group discussion tools will be used with teachers and mothers respectively.
 School physical environmental assessment will be carried out pre-post intervention. This will
 be followed by multi-component intervention phase with behavior change strategies to improve
 children's and mothers' hygiene K&P. The post-intervention phase will assess the intervention
 effectiveness in terms of enhancing hygiene K&P among schoolchildren and mothers, alongside
 exploration of mothers and teachers' insights into whether or not the intervention has
 brought changes in improving hygiene practices among children.

 Results: Paired T-test will be done pre-post intervention to measure the differences in
 knowledge and practice scores between mothers' hygiene literacy and practices with their
 child's knowledge and practices. Similar test will also be run to assess the differences in
 children' hygiene knowledge and practice scores pre and post intervention. Thematic analysis
 will be used for qualitative data.

 Discussion: Multi-component intervention aimed at improving personal and environmental
 hygiene among primary school children offers an opportunity to design and test various
 behavioral change strategies at school and home setting. The study findings will be
 significant in assessing the intervention effectiveness in improving children's overall
 hygiene.
Background:

 Globally, communicable diseases are prevalent among school age children and the exposure to
 variety of pathogens causing preventable diseases in school population is inevitable.
 Underlying factors mainly rests on poor personal hygiene and inadequate sanitation practices
 leading to school absenteeism and life threatening illnesses among children (if continually
 neglected in the long run). The situation is worse in low and middle income countries due to
 inadequate health care facilities leading to compromised health status of school children.

 Among communicable diseases, respiratory infections and diarrheal diseases are regarded as
 the deadliest killers of young children. Incidence of diarrheal disease in the initial years
 has been linked with impaired cognitive performance in the later childhood. In addition, in
 developing countries intestinal helminthic infection is a commonly cited problem among
 school-age children. Furthermore, oral health cavity infections are also commonly found in
 school going children worldwide. Frequent attacks of infection predispose young children to
 malnutrition and can form a vicious circle and retard children's physical and cognitive
 development. Moreover, the contextual factors such as poor socio-economic environment further
 deteriorate the health status of school children especially in low and middle income
 countries.

 In the Pakistani context, alongside pneumonia and diarrhea worm infestation and scabies among
 school age children are the commonly reported health issues; manifesting poor personal
 hygiene. An evaluation study on water, sanitation and hygiene intervention on school child
 performance in two cities showed that almost 48% of government school children avoid going to
 school toilets due to poor sanitary condition. In local context, studies are mostly focused
 on oral hygiene assessment among children, showing satisfactory knowledge about using tooth
 paste. Comprehensive assessment about personal and environmental hygiene assessment among
 children, teachers and parents has remained a gap. Poor knowledge and practice of, and
 attitudes to personal hygiene have negative consequences on their long term development. This
 necessitates the designing and testing of school-based interventions aiming to improve
 hygiene behaviors among children, thereby minimizing their potential to capture preventable
 illnesses.

 It is unfortunate that school health remains a neglected aspect of public health in Pakistan.
 In 2005, School Health Program was launched in 17 districts of the country by Ministry of
 Education, Pakistan in collaboration with United Nations Educational, Scientific and Cultural
 Organization (UNESCO). The program focused on various components including personal hygiene
 and environmental education but its impact was not determined . To the best of our knowledge,
 there is paucity of studies in Pakistan on school-based interventions to promote personal and
 environmental hygiene of school children, with child's parents and teachers' involvement.
 Towards designing school based programs, role of parents and teachers must be considered as
 they are the important role models for school going age children. And thus had detrimental
 effects in shaping children's overall health and hygiene behavior.

 In this paper, Investigators present a study protocol using mixed-methods study design to be
 implemented in schools of a peri-urban community setting, Pakistan. The proposed study aims
 to improve the knowledge and practices of school children towards personal and environmental
 hygiene through school based intervention. To our knowledge, holistic assessment of hygiene
 among school children has not been studied in the local context. And the intervention to be
 implemented (with behavior change communication using adult to child and child to child
 approach, assessment of education curriculum on hygiene concepts) has never been studied
 before.

 Primary research questions

 1. Does school-based hygiene intervention facilitate improvement in knowledge and practices
 among primary school children studying in semi urban schools, Pakistan?

 2. What are the enablers and barriers towards the adoption of personal and environmental
 hygiene practices by school children?

 Secondary research questions Does improvement in knowledge and practices among the mothers of
 primary school children studying in semi-urban schools contributes to improved knowledge and
 practices of school children?

 Methods Study design The study will employ a quasi-experimental design (pre-post intervention
 without control arm). The proposed study design is chosen as it will facilitate in evaluating
 school based interventions in the selected school settings without randomization. Similar to
 the randomized trials, quasi-experiments (community based trial) aims to demonstrate
 causality between an intervention and an outcome at the defined interval.

 Study settings The study will be conducted in District Malir, Gaddap town in Karachi,
 Pakistan

 Data collection methods The study is built on mixed method data collection approaches to gain
 insight of the hygiene literacy and practices among school children, teachers and child's
 mothers. Table 1 lists different data collection methods with its purpose and interval.

 Study phases The study has been structured into 3 phases - pre-intervention, intervention and
 post-intervention.
Inclusion criteria for Schools:

 * Primary schools run by government or / NGO functional in District Malir, Gaddap town of
 Karachi

 Exclusion Criteria for Schools:

 * Consent not given by school administration.

 Inclusion Criteria for Children:

 -  Students enrolled in primary grade (class 1-5)

 -  Informed consent given by either of the child's parents.

 -  After obtaining child's parents' consent, assent obtained from children.

 Exclusion Criteria for Children:

 * Assent not obtained from children

 Inclusion criteria for Mothers:

 -  Mothers whose children are studying in grade 1-5 in selected/sample schools will be
 recruited.

 -  Mothers available at the time of data collection

 -  Mothers who gave consent

 Exclusion Criteria for Mothers:

 * Mothers who didn't meet the above eligibility criteria is excluded to participate.

 Inclusion Criteria for Teachers:

 -  Teachers who are involved in teaching grade 1-5 students in the selected schools.

 -  Those who are available at the time of the study will be recruited after their
 informed consent.

 Exclusion Criteria for Teachers:

 * Those teachers who didn't give consent will be excluded.

 Inclusion Criteria for Key Stakeholders:

 -  District Education Officers (DEO) and District Health Officer (DHOs) who currently
 hold the offices will be interviewed.

 -  Interviews with these respondents will only be held after obtaining their informed
 consent.

 Exclusion Criteria for Key Stakeholders:

 * Stakeholders who didn't provide consent will be excluded