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EXPERIENCES FROM CWSA IN THE IMPLEMENTATION OF SCHOOL HEALTH EDUCATION PROGRAMME (SHEP) IN GHANA By: MRS. THEODORA ADOMAKO-ADJEI & EMMANUEL T NYAVOR SOGAKOPE, 18/09/07

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Outline of Presentation Programme background Objectives Achievements Findings of a multi-country research Challenges and the Way forward Research Areas

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Programme background The NCWSP has an objective to maximise health benefits through integration of water, sanitation and hygiene promotion The CWSA has, as part of its intervention strategies for improving Water Supply and Sanitation facilities, a School Health Education Component aimed at promoting personal hygiene, environmental cleanliness and nutrition in the basic and second cycle schools.

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Programme background OBJECTIVES Develop adequate,safe and sustainable water and sanitation facilities in schools in order to improve health of teachers and pupils To improve good hygiene and sanitation practices in schools with the aim of improving the health of teachers, schools and families.

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Programme background (contd) CWSA collaboration with GES began in July 1994 CWSA interventions in schools include : Provision of institutional latrines (and handwashing facilities) Provision of water facilities (where applicable) Training of District School Health Co-ordinators, Circuit Supervisors, Headteachers & School Health Teachers Training of school health committees School hygiene competitions. Research/studies.(KABP, Evaluation and sanitation study Development & production of hygiene promotion materials

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Objective of Training School Health Committees Develop the capacities of teachers, parents and food vendors in the schools provided with water and sanitation facilities and to outline strategies for the integration of educational activities that lead to sustainable changes in hygiene behaviour in the schools, home and the communities.

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Achievements Developed the curriculum on Water, Health and Sanitation for I st and 2 nd cycle institutions. (This has been been reviewed by SHEP HQTS) Total of 2303 KVIP latrines constructed from 1994-2006 Formed School Health Committees in 1556 schools Trained 1556 School health Committees Trained 3515 School health teachers

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Training Outcomes Most School Health Committees now receives full support from Parent Teachers Associations (PTAs) & Schools Management Committees (SMCs) in the implementation of SHEP through the provision of facilities such as: - liter bins with covers - dual purpose water storage facilities - urinals - school canteens

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Training Outcomes contd Most schools now have adequate and hygienic drinking water storage containers/ hand washing facilities) A significant increase in the number of pupils with individual drinking cups A significant number of pupils now wash hands with soap under running water after visiting the toilet School health committees ensure that food vendors are medically certified and sell food under hygienic conditions.

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DIFFERENT WATER STORAGE FACILITIES DESIGNED DURING TRAINING

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PUPILS NOW WASH HANDS WITH SOAP UNDER RUNNING WATER AFTER VISITING THE LATRINE & BEFORE EATING

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A PUPIL USING HER INDIVIDUAL DRINKING CUP TO DRAW WATER FROM A RECEPTACLE IN A SCHOOL

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Training Outcomes (contd.)

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Challenges Problem of Ownership & Management of institutional latrines (the schools do not have a budget for operation and maintenance) Abuse and vandalization of school latrines ( e.g. stealing of vent pipes & taps on handwashing facility ) Delays in payment of 10% capital cost contribution by the schools High turn over of trained School Health Coordinators and headmasters Inadequate hygiene promotion materials in schools

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Challenges contd Ineffective monitoring supervision by DA & GES; resulting in:- Shoddy work by some contractors

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AN EXAMPLE OF A SHODDY WORK DUE TO POOR SUPERVISION

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Challenges continued Lack of co-ordination among the stakeholders involved in water, sanitation and hygiene provision Some School Authorities and SMCs are not committed to school sanitation and hygiene education activities Absence or dormant school health committee School authorities not adhering to latrine user education (eg. alternate use of pits, putting all anal cleansing materials into the pit)

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An example of non adherence to user education

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Sustainability of changes in hygiene behaviour A multi-country study financed by the EC and DGIS (2000-2003)

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Study objective To asses the level of sustainability of behavioral changes 1 to 3 years after a hygiene promotion intervention.

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Research partners Network for Water and Sanitation International (NETWAS), Kenya WaterAid Uganda Community Water and Sanitation Agency, Ghana Nepal Water for Health Organisation (NEWAH) COSI-Foundation for Technical Cooperation, Sri Lanka Socio-Economic Unit Foundation (SEUF), India London School of Hygiene and Tropical Medicine German Agency for Technical Cooperation (GTZ) IRC-International Water and Sanitation Centre

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Key behaviours studied in schools Ten schools were surveyed for hygienic storage of water as seen through observation, skills in hand washing through demonstration, knowledge about critical times of hand washing and hygienic use and maintenance of institutional latrines

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Drinking Water Storage in Schools Hypothesis: If there is a project intervention in the community, then safe water is available in the school This hypothesis was not proven as many schools were not having any water storage receptacle and the few available were empty.

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Drinking Water Storage in Schools CONCLUSION: JUST HAVING A PROJECT INTERVENTION IN THE COMMUNITY IS NOT SUFFICIENT TO ENSURE THE AVAILABILITY OF STORED SAFE DRINKING WATER IN THE SCHOOL. IMPLICATIONS: Drinking water storage in schools not getting the needed attention. Children are most likely dehydrated and this is contributing to their stunted growth and learning abilities.

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HANDWASHING FACILITIES The assumption that schools would provide hand- washing facility if the project provide latrine did not hold. Only 2 schools out of the 10 had hand- washing facility, water and soap near the latrine for student use. CONCLUSION Schools failed to honour their part in the provision of hand washing facilities after construction of school latrines.

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Demonstration on Hand Washing techniques (N=440) 66% of school children use soap on both hands during hand washing. Out of these, 63.5% of them rub both hands in at least three different directions CONCLUSION: It is statistically proven that children in schools where latrines were clean did perfect handwashing demonstrations. IMPLICATION: Promotion of Clean Latrines and Hand Washing Facilities Should Be Intensified In Schools.

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Latrine Use and Cleanliness Hypothesis If there is a well functioning system of latrine maintenance (cleanliness as well as physical maintenance), then user rate by children is high. Cleanliness and maintenance of latrines seems to deteriorate over time. Only 2 out of 10 schools have clean and well-used latrine (ie free from puddles of urine, anal cleansing materials and faeces on floor). Conclusion If School Health Committees are functional, they have big impact on hygiene behaviours. Therefore strengthen SHCs and put in more resources for monitoring their performances and functionality.

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Lessons 1.In schools where the authorities are committed: Knowledge seems very good among children Latrines were clean and used Behaviours such as how to wash hands have been developed Teachers have instituted a system for maintaining latrines Periodic educational sessions are organised Food vendors have been screened, certified and sell under hygienic conditions Drinking water cum handwashing facilities are available and litter bins have been provided

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Lessons (continued) 2. Merely constructing water and sanitation facilities is not sufficient to induce good hygiene behaviours. Hygiene promotion /education are needed to achieve this 3. Successful hygiene education leads learners to develop and maintain new health behaviours 4.School hygiene programmes can easily fail if training and follow up are not made and if education authorities at all levels are not involved.

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Lessons (continued) 5. Regular supervision, follow up and monitoring is essential for proper operation and maintenance 6. Follow up and supervision is necessary to sustain SHEP activities, and to ensure that teachers apply the participatory tools that they learn to use during the training.

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The Way Forward Integrate School Health education into the initial teacher training programme as a curriculum policy of the GES Need for periodic capacity building for institutional latrine contractors and school heath committees The roles and responsibilities of the various stakeholders involved in the school hygiene programme need to be redefined by SHEP Headquarters Foster collaboration between DWST, GES, GHS and other stakeholders through regular inter-sectoral meetings

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The Way Forward (contd) District Directors of Education should ensure that school health committees are formed/reactivated in all schools District SHEP Coordinators, Community Health Nurses and Environmental Health Officers should play a more visible role in monitoring cleanliness in schools and supporting teachers in the teaching of hygiene DAs and GES should provide adequate resources to the field staff to ensure regular monitoring and supervision of water and sanitation facilities in schools/communities

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The Way Forward (contd) SHCs and Circuit Supervisors should ensure that all schools have water storage containers fitted with tap. (the practice of communal hand washing in a bowl should be discouraged) There is the need to explore technological options that could be more child and gender- friendly.

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Possible Research Areas Investigating the sustainability of hygiene behaviour changes in schools and communities (this should be done in all the ten regions) Assessing the impact of the use of children as change agents in the beneficiary communities. Assessing the filling rate of institutional KVIP latrines Investigating the suitability/user-friendliness of Institutional KVIP latrines Pathogenic safety test for compost (decomposed faeces from KVIP latrine)

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