Teaching Hand-washing in Primary Schools
Project: HiFive (Phases I and II)
Client: UNICEF WASH Philippines
Partners: Philippines Department of Education (DepEd), International WaterCentre (IWC)
Dates of service: 2017-2019
IDinsight service: Randomized evaluation, Process evaluation
IDinsight contacts: Lilian Lehmann, Clement Bisserbe, Meg Battle, Crystal Haijing Huang, Jeff McManus
Additional Documents: IDinsight UNICEF HiFive Evaluation Report Phase I (2018), IDinsight UNICEF HiFive Evaluation Report Phase II (2019)
Additional Resources: HiFive Phase III
School children in the Philippines suffer from a high burden of preventable diseases, with hygiene deficiencies identified as a common cause. Hand-washing with soap is considered one of the most effective measures to reduce respiratory tract infections and diarrhea and prevent the transmission of infectious diseases.
To promote improved individual hand-washing behaviors, the Philippine Department of Education (DepEd), UNICEF and IWC designed the HiFive for Hygiene and Sanitation (HiFive) program. The intervention was piloted in 198 schools across Camarines Norte and Puerto Princesa in two phases from 2017-2019.
The HiFive program is a 6-week school-based campaign that involved teachers conducting five classroom activities using behavioral messaging to motivate pupil independent hand-washing with soap (iHWWS) at critical times (before eating and after toilet use). The program was also intended to encourage teachers and principals to increase the availability of clean and functional hand-washing and toilet facilities with soap. DepEd and UNICEF wanted to know whether to incorporate the campaign in the national WASH in Schools policy.
In 2018 (Phase 2) DepEd and UNICEF revised the implementation of the HiFive for Hysan program to strengthen the communication of key behavioral motivators, strengthen the training, and monitoring systems, and integrate HiFive activities into school lesson plans. As with Phase I, DepEd and UNICEF wanted to know whether to incorporate the HiFive campaign and accompanying lesson plans in the national WASH in Schools policy.
IDinsight Service Phase I:
IDinsight conducted an impact evaluation of the HiFive intervention pilot using a clustered randomized controlled trial. Half of the 196 schools were randomly selected to receive the HiFive intervention and the remaining half were controls. Data was collected on grades 1-3 and 4-6 in order to evaluate effects on older and younger pupils. The primary objective of the evaluation was to estimate the effect of the intervention on iHWWS at critical times by pupils.
In addition, the evaluation sought to understand the impact of the HiFive intervention on:
The frequency of daily supervised group hand-washing activities in schools
The availability of functional hand-washing and toilet facilities
Motivations and critical times reported by pupils for practicing iHWWS
A process evaluation was also conducted to substantiate the results of the impact evaluation, identify implementation challenges, and inform potential improvements to the design of the HiFive intervention.
IDinsight Service Phase II:
IDinsight conducted a pre-post analysis and process evaluation of the revised intervention, which was delivered in the remaining 98 control schools across Camarines Norte and Puerto Princesa the following school year (2018). The objectives of the evaluation were to assess its implementation quality and effect on handwashing rates.
Results Phase I :
The evaluation found that the HiFive intervention led to a small increase in the frequency of iHWWS at critical times. However, the rate of iHWWS remained low overall, with an average of 2.2% among grade 1-6 pupils in control schools. Observed rates of iHWWS after toilet use were 3.7 pp. higher in grades 1-3 at treatment schools and 2.1 pp. higher in grades 4-6. The rate of reported group hand-washing among grade 4-6 pupils was 15.3 pp. higher in treatment schools. Access to hand-washing facilities with soap was high relative to hand-washing rates, and the intervention increased the availability of soap at facilities near toilets by 10.3 pp. The intervention did not significantly shift pupil perceptions of critical times or motivations to wash hands. While there did not appear to have any major deviations from the intervention design in the implementation, the process evaluation identified gaps in the design and delivery of the HiFive tools which may have reduced their effectiveness.
Given the high level of hand-washing knowledge among pupils, as well as widespread access to hand-washing facilities, IDinsight recommended that UNICEF retain HiFive’s behavioral approach. IDinsight also recommended that UNICEF pursue a Phase II pilot with revised tools rather than scale up the program.
Results Phase II:
The study found that hand-washing rates after toilet use in HiFive schools increased from 2.5% to 7.6% (+5.1 pp.), driven primarily by increased individual hand-washing among pupils in grades 1-3. This change is slightly larger than the program effect found by the Phase I evaluation (+3.7 pp.). In particular, improved teacher training and curriculum integration were identified as key factors that led to a more effective rollout in Phase II. Findings from the process evaluation also suggests stronger implementation and monitoring than the Phase I pilot. However, the post-program rate of hand-washing remains critically low.
Impact Phase I:
Based on the IDinsight results, UNICEF and DepEd revised the intervention design to strengthen the communication of key behavioral messages and use the next phase of the pilot to test the revised HiFive intervention and identify further improvements in its implementation. IDinsight and UNICEF renewed their partnership to generate evidence for the Phase II pilot in 2018.
Impact Phase II:
Despite widespread access to functional hand-washing facilities and high levels of pupil knowledge of good hand-washing practices, the vast majority of pupils did not wash their hands with soap after using the toilet. IDinsight recommended that UNICEF and DepEd test alternative approaches, such as behavioral nudges that have been shown to be effective at increasing hand-washing rates in other settings, in the Philippines context. Based on these recommendations, UNICEF and DepEd did not scale up or promote HiFive activities or lesson plans. We recently launched a new phase of work to test behavioral nudges’ impact on pupils’ hand-washing behavior.