SOLOMON TOMMY - KAP UNICEF Rolling Research Presentation

SOLOMON S. TOMMY

KNOWLEDGE, ATTITUDE AND

PRACTICE OF HANDWASHING

AMONG CAREGIVERS OF

UNDER-FIVE CHILDREN IN LAGOS

STATE

Outline

Background

Aim and objectives

Literature review

Theoretical framework

Methodology

Results and conclusions

BACKGROUND

• According to Nte (2012), despite remarkable improvements since the turn of the 21 st century, there has been insufficient progress in child survival, especially in low-resource countries as only 23 Countdown countries were on track to achieve MDG 4, while others, including Nigeria, had made little or no progress.

• The high risk for U5 deaths in Nigeria is further validated by 2010 figures. The 6,332,000 live births and 861,000 U5 deaths estimated for Nigeria puts Nigeria’s U5 deaths to total live births ratio (13.6%) at about 2.5 times the global figure (5.6%)!

• While several other socio-economic bases exist for this trend, literature suggest that there is a direct association between child mortality and poor hygiene, as two leading causes of childhood mortality – diarrheal disease and acute respiratory infection – are consequences of poor hygiene

• Different studies have shown that hand washing is key in hygiene management, in a bid to reduce U5 mortality (Bowen et al 2007; Luby et al 2009).

• In fact, Lancet (2008) and Saha et al (2009) agree that hand washing with soap before preparing children’s food is one of the best ways to prevent infections, poor appetite, and eventually malnutrition and death.

• This has informed the drive to promote hand washing as a means to reducing U5MR and help national governments’ push to achieve MDG 4. This campaign has been led by MNCs (e.g. Unilever, PZ , etc) under a PPP platform, and aided by huge budget marketing and social engagement campaigns intended to increase knowledge, influence on attitude and foster adoption of hand washing, especially among children and caregivers.

• This informed the purpose of this study, which was, to determine the extent to which caregivers in Lagos State know of hand washing (especially as a means to promote child health), their attitude towards it, and the extent to which they practice hand washing

BACKGROUND

AIMS AND OBJECTIVES

GENERAL AIM AND OBJECTIVE OF THE STUDY

To determine the extent to which caregivers of U5 children in Lagos State know of handwashing as a practice (and the health implications of non-practice);

And the extent to which this knowledge influences perceptions and attitudes to handwashing, as well as the practice of handwashing.

SPECIFIC OBJECTIVES

Determine the level of exposure to information on hand washing among under-five caregivers in Lagos State

Determine the level of knowledge of hand washing among under-five caregivers in Lagos State

Assess the disposition of under-five caregivers in Lagos State to hand washing

Determine under-five caregivers’ disposition to hand washing as a means of reducing diarrheal diseases among children in Lagos State

Determine the extent under-five caregivers in Lagos State practice hand washing

Identify the factors that influence hand washing practice among under-five caregivers in Lagos

LITERATURE REVIEW• The high rate of U5 deaths has been well-documented, as well as the major causes, which

according to WHO (2001) include measles (2%), AIDS (5%), malaria (13%), acute respiratory infections (32%), diarrheal diseases (35%), and others, including malnutrition (13%). There is a direct causal relationship between the three major killers listed and poor hygiene (Curtis and Calmcross 2003; Dutton, Peschiara and Nguyen 2011; Pengpid and Peltzer 2012).

• This pressing concern, is being tacked globally under the auspices of WASH (Water, Sanitation and Hygiene) promoted by the United Nations, and has hand washing with soap as one of the proactive means of stemming the contributions of suboptimal hygiene to U5MR.

• Hand washing is defined by the Center for Disease Control (2009) as the vigorous, brief rubbing together of lathered hands following by rinsing under a stream of water. This places emphasis on the use of soap.

• October 15 is now being celebrated globally as the Hand Washing Day, to serve as rallying point for all endeavours to promote this inexpensive but life-saving habit

• However, given the continued state of U5MR in Africa and Nigeria, which Nte (2012) records to still be high, it would suggest that there is poor adoption of hand washing with soap, especially among caregivers.

• The study of knowledge, attitude and practices(KAP) of hygiene (hand washing) therefore remains essential in African countries, especially with the different intervention programmes being championed by government, private companies – via a shared values approach to CSR, community-based groups and philanthropic individuals.

• These interventions are designed to respond to the gaps in KAP, especially given the degree to which regular hand washing is accepted as a norm.

• Although Curtis and Cairncross (2003) and Vivas et al (2010) are in agreement that the knowledge of the consequences of poor hygiene serves as a motivation, this has not reflected significantly on adoption. Hence, they argue that even though there may be an appreciable level of knowledge of, and a positive disposition to, hand washing as a part of hygienic practices, the level of practice is rather low.

• This brings to play the influence of impeding factors responding for the low practice, which may range from socio-economic (lack of access to adequate (running) water, ability to buy soap, access to information, etc) to attitudinal.

LITERATURE REVIEW

ENTERTAINMENT EDUCATION MODEL

THEORETICAL FRAMEWORK

DIFFUSION OF INNOVATION

SOCIAL MARKETING

HEALTH BELIEF MODEL

The Health Belief Model (HBM) is a psychological model that helps to predict and explain behaviours. It holds that individual behaviour changes (such as hand washing) are founded on how serious a person believes is the perceived threat of contracting the disease or illness.

This theoretical construct seeks to explain the trajectory of the spread and adoption of new practices, as would apply to hand washing in this context; the course by which an innovation is transmitted through certain channels over time among the members of a social system.

Social marketing, as defined severally, is the adaptation of commercial marketing techniques to social goals, involving a merger of interpersonal and mass communication channels incorporating specific vehicles such as advertisements, experiential marketing techniques like PZ Cussons and Proctor and Gamble are doing

In the area of health promotion, entertainment-education is a strategy that has been applied to maximise the reach and efficacy of communication efforts through the blend of entertainment and education, especially as it pays attention to behavioural change through the dissemination of information.

A descriptive cross- sectional approach was used for this study. Survey was the main research method, while focus group discussions (FGDs) served to complement survey findings.

The study location was Lagos State.

Bearing in mind the influence of socio-economic demographics on WASH, the study location was divided into three socio-economic category (SEC): high income (A and B SEC), middle income(C1&2 SEC),and low income(D, E SEC)

For this study, the Eti-Osa, Lagos Mainland, and Alimosho LGAs served as the representative LGAs for the respective SECs, based on studies by Okuneye et al (2006) and CLEEN Foundation (2011) which identified these LGAs respectively as high income, middle income, and low income LGAs.

RESEARCH METHODOLOGY

The population for this study were caregivers of U5 children, which in this case applied to mothers, relatives/helps, operators of pre-school centres, etc. However, the sampling frame will be restricted to mothers of U5 children.

Inclusion criteria were nursing mothers with children under the age of 18 months, while mothers with U5 children who have not had a diarrheal or respiratory ailment in six months were excluded


To determine the sample size for this study, the formula to be used is

n = z2pq

d2

Where n= Sample size

z= Standard normal deviate, usually set at 1.96

p= Proportion of the population that have desired characteristics. In this case, this is assumed to be 40 percent (0.4); q= p – 1, which in this case is 0.6; and d= Degree of accuracy desired, usually set between 0.02 and 0.05. In the case of this study, d was

set at 0.05

Based on this, the sample to be studied amounted 368.8, approximately 369. A 10% attrition rate was provided for, which brought the final sample to 406. This will be proportioned relative to the total population of each of the LGAs.

12 respondents to the FGD, four from each zone, will be selected from this sample.


The sampling technique was the multistage sampling technique. At the first stage, the study location was reduced to one local government each, eliminating the other LGAs and LCDAs, using a judgmental sampling technique already established.

In the 2nd stage, a list of the wards which made up the three local government areas were acquired from the LGA secretariats, and using the systematic SRS, three wards each per LGA from the list of wards per LGAs were selected.

At the 3rd stage, three (3) communities were then selected from the nine wards through SRS using computer-generated random numbers. Finally, respondents were selected from three (3) streets each per community using SRS based on the proportion-based sharing.

Contribution of the LGAs were as follows: Eti-Osa (287,785) = 51; Lagos Mainland (317,720) = 80; and Alimosho (1,217,714) = 275

Focus group discussion participants were selected from among the already selected sample based on consent to participate.


The key data collection tool for this study was the structured questionnaire and the moderator guide, which were a list of questions deriving from the research questions, and designed to provide answers to the research questions.

The instrument was divided into three sections, one each asking questions bordering on knowledge, attitudes and practices.

Five data collectors were trained for 20 hours spanning over a period of four (4) weeks – given the researcher’s work schedule – and then sent out to the field to administer the research instruments.

Collected data were subjected to statistical analysis using SPSS 16.0 which looked to test relationships, especially between demographic variables and hand washing knowledge, attitudes and practices using regression analysis.

Statistical significance was set at α ≤ 0.05, and data from the survey were presented in prose, complemented with frequency distributions in tables and percentages.

To address ethical issues, the respondents were asked for their written or oral consent before the research instrument will be administered, and permissions were granted by the Department of Mass Communication, UNILAG, and LGA chairmen. Efforts will be made for community engagement, especially in identified low-practice areas, in partnership with LGAs and sponsoring organisations


RESULTS AND CONCLUSIONSRESEARCH QUESTIONS

To what extent are under-five caregivers in Lagos State exposed to information on hand washing?

How much knowledge of hand washing do under-five caregivers in Lagos State have?

What is the disposition of under-five caregivers in Lagos State to hand washing?

To what extent do under-five caregivers see hand washing as a means of reducing diarrheal diseases among under-five children in Lagos State?

To what extent do under-five caregivers in Lagos practice hand washing?

What factors influence hand washing practice among under-five caregivers in Lagos?

RESEARCH HYPOTHESES

H0: There is no significant relationship between level of knowledge and practice of hand washing among under-five caregivers in Lagos State.

H0: There is no significant relationship between dispositions to hand washing and practice of hand washing among under-five caregivers in Lagos State.

H0: There is no significant relationship between access to running water and the practice of hand washing among under-five caregivers in Lagos State.

H0: There is no significant relationship between education of respondents and practice of hand washing among under-five caregivers in Lagos State

RESULTS: demographics

18-25

26-33

34-41

42-50

51+

0 20 40 60 80 100 120 140 160 180

88

166

61

46

31

Age

Age

Single

Married

Separated

Divorced

0 50 100 150 200 250

131

210

23

7

Marital status

Marital status

None

OND/NCE

M.A/M.Sc

0 20 40 60 80 100 120 140

43114

78116

212

Academic at-tainment

Academic attainment

Unemployed

Self-employed

Paid employment

0 20 40 60 80 100

120

140

160

180

80

117

165

Employment status

Employment status

EXPOSURE TO INFORMATION ON HANDWASHING

48%

26%

3%

17%

5%2%

Exposure pattern

Daily> 2 times/week< 2 times/weekWeeklyRarelyNever

RESULTS: Research question one

RESULTS: Research question two

KNOWLEDGE OF HANDWASHING

As the table shows, 42% of respondents believed the average time for proper hand washing is 15 seconds;

78.6% of them felt in a period of 12 hours, one should wash his/her hands for an average of 3 to 4 times

30.4% say proper hand washing is possible without the use of any other agent apart from water.

What all these show is that there is a mixed display of knowledge by the respondents.

But with a score mean of 44.3%, it means those who had adequate knowledge of what hand washing is all about are not up to half of the under-five care givers.

Knowledge Frequency Percentage

The average time for proper hand washing is 15 seconds

158 42

Proper hand washing is possible without the use of any other agent apart from water

114 30.4

Hand washing helps to prevent pneumonia

137 36.7

In a period of 12 hours, one should wash his/her hands for an average of 3 to 4 times

290 78.6

A child can die due to non-practice of hand washing

212 56.7

Ash can be used during hand washing

80 21.6

N = 374 (100%)

KNOWLEDGE OF HANDWASHING

RESULTS: Research question threeDISPOSITION TO HANDWASHING

Handwashing is healthy practice

Handwashing is necessary

Handwashing important but wastes time

Handwashing only when convenient

Others

0 50 100 150 200 250 300 350

287

54

20

3

2

Disposition to handwashing

Disposition to handwashing

RESULTS: Research question fourHANDWASHING AS MEANS TO COMBAT DIARRHEAL

DISEASES

96%

2%2%

Handwashing as means to combat di-arrhoeal diseases

Yes, it isNo, it is notI cannot say

RESULTS: Research question fiveHANDWASHING PRACTICE

Yes No Not sure0

100

200

300

400

301

22 47

Practice of handwashing

Practice of handwashing

Yes No Not sure0

50100150200250

Handwashing with soap

Handwashing with soap

Yes No Not sure

94

280

0

Use of sanitisers

Use of sanitisers

1-10 secs 11-20 secs 21-30 secs 31+ secs

120 113

7464

Time spent handwashing

Time spent handwashing

RESULTS: Research question sixFACTORS INFLUENCING HANDWASHING PRACTICE

Yes

No

Not sure

0 50 100 150 200 250 300

262

81

18

Water access and handwashing

Water access and handwashing

Yes

No

Not sure

0 50 100 150 200 250

233

74

65

Mass media info and handwashing

Mass media info and handwashing

Don't want child to fall sick

Because of advert

Life-long habit

Others

0 20 40 60 80 100 120 140 160 180 200

17337

2140

6928

3

Reasons for handwashing

Reasons for handwashing

HYPOTHESIS ONE: knowledge and practice

P Value = 0.000 = 0.000 < 0.05: This shows that there is very strong relationship between the variables in the tables.

R square = 0.035 which is equivalent to 35% indicates the strength of the relationship to be not very high.

Coefficient of variable = 0.188 is positive indicating a positive slope, indicating that the two variables increase or decrease with each other.

At the degree of freedom of 1, the P value equals 0.000 and no cell having expected frequency less than 5, where the minimum expected frequency is 7.66, the value of P (0.000) is less than 0.5%.

From the analysis above, the null hypothesis was rejected while the alternate was accepted.

Coefficientsa

.957 .097 9.831 .000 .766 1.148

.290 .080 .188 3.622 .000 .133 .448

(Constant)

VAR00002 haveyou heard abouthand washing?

Model1

B Std. Error

UnstandardizedCoefficients

Beta

StandardizedCoefficients

t Sig. Lower Bound Upper Bound

95% Confidence Interval for B

Dependent Variable: VAR00018 do you practice hand washing?a.

ANOVAb

5.981 1 5.981 13.122 .000a

163.631 359 .456

169.612 360

Regression

Residual

Total

Model1

Sum ofSquares df Mean Square F Sig.

Predictors: (Constant), VAR00002 have you heard about hand washing?a.

Dependent Variable: VAR00018 do you practice hand washing?b.

Model Summary

.188a .035 .033 .67513Model1

R R SquareAdjustedR Square

Std. Error ofthe Estimate

Predictors: (Constant), VAR00002 have you heardabout hand washing?

a.

HYPOTHESIS TWO: dispositions to hand washing and practice


R square = 0.324 which is equivalent to 32.4% indicates the strength of the relationship to be not very high.

Coefficient of variables = 0.569 is positive indicating a positive slope, indicating that the two variables increase or decrease with each other.



Model Summary

.569a .324 .322 .56924Model1



Predictors: (Constant), VAR00016 indicate yourattitude towards hand washing

a.

ANOVAb

55.894 1 55.894 172.495 .000a

116.651 360 .324

172.544 361

Regression

Residual

Total

Model1


Predictors: (Constant), VAR00016 indicate your attitude towards hand washinga.


Coefficientsa

.583 .062 9.461 .000 .462 .704

.536 .041 .569 13.134 .000 .455 .616

(Constant)

VAR00016 indicateyour attitude towardshand washing

Model1

B Std. Error


Beta





HYPOTHESIS THREE: access to running water and practice



Coefficient of variables = 0.473 is positive indicating a positive slope, indicating that the two variables increase or decrease with each other.



ANOVAb

43.444 1 43.444 103.077 .000a

150.887 358 .421

194.331 359

Regression

Residual

Total

Model1


Predictors: (Constant), VAR00023 do you always having portable water in yourhome?

a.


Coefficientsa

.522 .087 5.981 .000 .350 .693

.615 .061 .473 10.153 .000 .496 .734

(Constant)

VAR00023 do youalways having portablewater in your home?

Model1

B Std. Error


Beta





HYPOTHESIS FOUR: education of respondents and practice



Coefficient of variables = 0.-170 is negative indicating a negative slope, indicating that the two variables decrease with each other.



Model Summary

.170a .029 .026 .71817Model1



Predictors: (Constant), VAR00029 educationa.

ANOVAb

5.627 1 5.627 10.909 .001a

189.803 368 .516

195.430 369

Regression

Residual

Total

Model1


Predictors: (Constant), VAR00029 educationa.


Coefficientsa

1.631 .099 16.411 .000 1.436 1.827

-.105 .032 -.170 -3.303 .001 -.168 -.042

(Constant)

VAR00029 education

Model1

B Std. Error


Beta





Exposure to hand washing information was quite high among mothers of under-five children.

However. less than half of the respondent under-five caregivers had adequate knowledge of what hand washing is all about.

There was a very positive disposition towards hand washing among under-five caregivers in Lagos State.

It was found that respondents generally accept that hand washing is a good way to fight diarrheal and respiratory diseases

The availability of portable water plays a very crucial role of influencing the decision to wash hands.

While the practice of hand washing was high among under-five care givers in Lagos, they really weren’t doing it the hygienic way because when they washed their hands, to an extent, they were not using soap or sanitizers.

RESULTS AND CONCLUSIONS

Information about hand washing from mass media has been influential in improving hand washing practice

There is a significant relationship between level of knowledge and practice of hand washing among under-five caregivers in Lagos State.

There is a significant relationship between dispositions to hand washing and practice of hand washing among under-five caregivers in Lagos State.

There is a significant relationship between education of respondents and practice of hand washing among under-five caregivers in Lagos State

There is a significant relationship between access to running water and the practice of hand washing among under-five caregivers in Lagos State

RESULTS AND CONCLUSIONS

One, the campaigns by the international agencies like WHO to prevent diseases such as diarrhea among under five children are making desired impact as knowledge is high among caregivers in Lagos. However, it is not only the knowledge that is high; practice and positive disposition ratings are also high among caregivers.

Two, as this study has found, education is key to adoption of messages and practice of caregivers because those who are educated naturally will practice hand washing and take it more serious than those who are not. Getting information regarding the advantages of hand washing helps validate their regular practice.

Three, any success that may be recorded or hope to be achieved is a function of whether the caregivers have access to portable water in their locality. Access to water is central to the success of hand washing campaign and adherence as those who do not have not have access to portable water will find it difficult to practice it.

Four, attitude and general disposition play a major in how the under-five caregivers engage in hand washing. As this study has shown, the selected caregivers are favourably disposed to hand washing and this is one of the factors that influenced their practice.

CONCLUSIONS

The outcome recorded by this study suggests that with room for improvement, the campaigns from international organisations are influencing the way under-five caregivers become aware of the need to practice regular hand washing. It is hereby recommended that since those who are aware as at the time of this study are less than half the population, the sponsors of the campaign should intensify efforts and increase exposure slot in the mass media in order to get more caregivers know about the benefits of hand washing.

As the study has revealed so far, the practice of hand washing among the caregivers is impressive, but there is room for improvement. Efforts should therefore be made through the international agencies with supports from local authorities in the country to make more caregivers to practice and engage in washing their hands at all times in order to prevent diseases of different types to children under five years.

As it has been established, the practice of hand washing by selected caregivers in Lagos depends on a number of factors like education, disposition and access to water. The sponsors of the campaign should consider these factors whenever they are designing the campaign in order to address issues that may not permit caregivers to practice hand washing. Intervention efforts will be considered more strategic if they are designed to address the infrastructure gaps that negatively impact on the availability of these factors, particularly, access to water, if improvement is to be achieved in terms of practice.

RECOMMENDATIONS

Beyond mass media campaigns, there is the need also for interpersonal and community campaigns as a means of ensuring that hand washing becomes a part of popular culture. Opinion leaders, socio-political leaders, and even celebrities can form part of the campaign to encourage people, especially caregivers of under-five children, to practice hand washing, not as a passing fad, but as a survival lifestyle. A good way to achieve this would be through celebrity endorsements.

Repeated exposure has been found to impact positively on knowledge. Thus, intervention campaigns through media and non-media channels must therefore be strategically continuous, as an obvious means of setting agenda towards hand washing as a means of ensuring child survival.

This research study was carried out in three Lagos LGAs. It is hereby recommended that studies should be carried out in future which would cover other LGAs in Lagos and can be extended to the entire country, in order to establish how caregivers in other areas are practicing hand washing to prevent diseases that could kill their children.

RECOMMENDATIONS

THANK YOU

SOLOMON TOMMY - KAP UNICEF Rolling Research Presentation

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