Empowering kids to safeguard their health

As he approached a rural elementary school in India’s Uttar Pradesh state, Anvesh Badamikar  noticed boys urinating on the building’s outer walls. Badamikar, a graduate researcher with Stanford’s Program on Water, Health & Development (WHD) at the time, was there to learn how conditions of school bathroom facilities affect students’ sanitation practices. He was in for a dirty surprise.

Video by Madison Pobis, Anvesh Badamikar, and Tom Johnson.

Badamikar’s site visit was part of an effort to assess an initiative aimed at empowering school children to practice healthy sanitation and hygiene behaviors. The curriculum features fun and friendly characters who playfully teach kids how to wash their hands, identify safe water sources, and properly use latrines. The characters model behaviors and provide language to talk about taboo topics, such as toilet use. World Vision, a leading nonprofit provider of clean drinking water in the developing world, partnered with a leading child education and development organization to develop the contextualized behavior change curriculum. The have reached more than 18 countries with this curriculum. In conjunction, World Vision also ensured that all the target schools with basic facilities, such as adequate drinking water supply, functional gender-segregated toilets, and hand washing stations.

Water- and sanitation-related illnesses kill more than 1,000 children under five every day and are the second leading cause of infant mortality, according to UNICEF. Good hygiene and access to clean water and sanitation are the solution, but it remains unclear how to most effectively change related behaviors. In India, the problem is acute.

The school-based WASH behavior change curriculum was first rolled out in Zambia in 2017. WHD researchers trained enumerators there to interview teachers, parents, and students to understand the curriculum’s effect on community sanitation practices and health outcomes.

Among the takeaways from Zambia: first graders’ knowledge of germs and identification of unsafe drinking water, sources increased by 40%, and all students exposed to the curriculum were up to three times more likely to share messages learned at school with their families. Students seemed to enjoy the curriculum, and the messages stuck, but many lacked the facilities necessary to practice the healthy behaviors they learned.

Jenna Davis speaks with students in a school courtyard.

Of course, curriculum can only go so far. It’s a story WHD Director Jenna Davis is all too familiar with from her time assessing similar education programs in low- and middle-income countries.

“I saw lots of learning and excitement among the students, followed by disappointment and shame because they were unable to practice the healthy behaviors they were being taught,” Davis said. “That's because their schools didn't have working water points, toilets, and handwashing infrastructure, and the educational programs largely ignored the issue of an enabling environment.”

To provide clean, functional sanitation and hygiene facilities in India, project partner OPM worked with a local agency to hire and train about 100 custodians, and set up accountability mechanisms for them. To sidestep social taboos and instill the custodians with a sense of pride, they were given the title swachhata saathi, which means cleaning partner in Hindi. In addition to cleaning, the custodians were responsible for reporting broken infrastructure or inadequate supplies, such as soap at handwashing stations.

In India, a lack of clean, functional sanitation and hygiene infrastructure is sometimes aggravated by related deep social taboos.

“I was sometimes nervous to talk about these taboo topics. This was partially for my own sake, but also because I was conscious of the emotional weight and shame school staff might experience,” said Gracie Hornsby, a graduate student in civil and environmental engineering who is writing her dissertation on the India project. “Instead, teachers seemed relieved that someone recognized they are closest to the problem and are the experts on the topic.”

Gender issues present another major obstacle. Women and girls contend with inadequate facilities and stereotypes that burden them disproportionately with cleaning toilets, fetching and boiling water and taking care of those suffering from diarrheal disease. So, the WASH behavior change curriculum highlights the importance of girls and boys having separate and functional toilet facilities at school, while sharing responsibilities for handling water, washing, and maintaining cleanliness at school and home.

“We need to focus on gender equity from early on,” said Swati Agnihotri, a project manager on the project. “We want to change the mindset.”

The researchers analyzed results in schools with no intervention, schools with only the curriculum, schools with only daily bathroom custodians, and schools with both the curriculum and daily custodians. A final analysis is expected by this fall.

Along the way, COVID shutdowns, cultural taboos around bathroom cleaning, poor road conditions, and other obstacles sometimes stalled progress. Still, school visits by Badamikar and others increasingly found once-locked and filthy bathrooms now accessible and cleaned daily. Students energized by their WASH UP! lessons were becoming accustomed to having clean, working toilets and taps.

“The challenge now is to cement the maintenance program and the culture shift we’ve seen in schools,” said Badamikar. “That’s what will drive truly sustainable change, not just for these students but for the cohorts that will follow them."

Davis is also associate dean for integrative initiatives in institutes and international partnerships, professor of civil and environmental engineering in Stanford’s School of Engineering, and Higgins-Magid Senior Fellow at the Stanford Woods Institute for the Environment.