Project

Role of Hand Washing Hygiene in Prevention of Under-Five Diarrheal Diseases

Golden Hands Program Plan

for

Preschool Children

at

Obafemi Awolowo University International Staff School, Ile-Ife, Osun State, Nigeria

Oluwasola Ayosanmi, Chukwuebuka Ogwo

Save The Children (STC) Team

Western Illinois University, Macomb, Illinois

Golden Hands Program, 2

EXECUTIVE SUMMARY

Diarrheal disease has been noted as one of the commonest causes of mortality in under

five children globally (United Nations Children's Fund (UNICEF), 2017). The diarrheal disease

burden among under five children is enormous in Nigeria (World Health Organization (WHO),

2016). In fact, approximately 37 percent of the preschool children in Nigeria suffer from a

diarrheal disease at any given time (Okeke et al, 2000). A major source of this infection is a lack

of good hygiene practices. Of interest is that hand washing hygiene is a major factor in the

prevention of infections from the microbes that are involved in diarrheal disease, which is most

often caused by feco-oral transmission (Curtis, & Camicross, 2003).

The Save the Children (STC) team has embarked on a preventive health program named

Golden Hands Program, which will be adopted among the preschool children at Obafemi

Awolowo University (OAU) International Staff School, Ile-Ife, Osun State, Nigeria. Golden

Hands Program is developed with the mission of promoting childhood well-being and preventing

diarrheal diseases among the preschool children. It is the hope of STC that the Golden Hands

Program will enhance the adoption of hand washing hygiene practices among children. The

ultimate outcome pursued by STC is to reduce the incidence of diarrheal disease among

preschool children at OAU International Staff School by 50 percent.

Golden Hands Program Intervention will run for 30 weeks, and funded through a grant of

$15,000. Save the Children Team (STC) will install a borehole facility and three hand washing

basins at OAU International Staff School as part of the intervention for the Golden Hands

Program. There will be a kickoff ceremony for community sensitization followed by eight-week

learning periods for the preschool children to enhance mastery of the hand hygiene practices.

Golden Hands Program, 3

PROGRAM RATIONALE

Diarrheal disease is one of the oldest diseases in humans (Centers for Disease Control,

and Prevention, 2015). Diarrhea can be defined as the excretion of three or more loose or watery

feces daily (or frequent stooling abnormal for the individual) (World Health Organization WHO,

2003). Diarrhea is usually an indicator of intestinal tract infection, which can be caused by a

variety of microorganisms like viruses, bacteria and parasites, resulting in a marked loss of

essential body fluid and electrolytes and ultimately causing death (WHO, 2016). Diarrheal

disease-causing pathogens are often transmitted via the feco-oral means (Curtis, Cairncross, &

Yonli, 2000) through intake of infected food and water, immediate contact with infected fecal

matter, or by person-to-person contact (Eisenberg, Trostle, Sorensen, & Shields, 2012). Some

clinical trials have shown that more than 75 percent of diarrhea cases can be linked to food and

water contamination (Curtis, Cairncross, & Yonli, 2000) (Maxwell, Oklo, & Bernard, 2012).

Globally, nearly two billion cases of diarrheal disease occur annually and roughly two

million children below the age of five, mostly in developing countries, succumb to this condition

(MacGill, 2017). It is the second most common cause of under-five mortality behind respiratory

infections and it is largely preventable and treatable (WHO, 2016). In 2011 alone, about three-

quarter of a million children below the age of 5 years were lost to the complications of diarrhea

(Lamberti, Fischer Walker, & Black, 2012). Diarrhea accounted for nine per cent of all under

five mortality recorded worldwide in 2015, which means that more than 1,400 children die daily,

or about 526,000 children annually, in spite of existing simple effective cure regimen (UNICEF,

2017). An estimated 72.8 million disability-adjusted life years (DALYs) is lost annually via

disability and early mortality, especially in resource poor countries (Murray, Vos, Lozano,

Naghavi, Flaxman, & Michaud, et al. 2012).

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About 42 percent of the global diarrhea burden occurs in the WHO African region

(Bryce, Boschi-Pinto, Shibuya, & Black, 2005). Despite the global decline in mortality rates in

children from 146 per 1,000 live births in 1970 to 79 per 1,000 live births in 2003 (WHO, 2005),

the story is markedly different in Africa. In comparison to other world regions, the African

region has the least reduction rate in deaths and the most remarkable trend in decline. The rate of

under-five mortality in Europe is seven times lower than that in Africa (WHO, 2005).

Several factors contribute to high rate of diarrhea under five in Nigeria and they include

poor hand washing hygiene of caregivers, poor food and water sanitation, lack of rotavirus

vaccination, and poor breastfeeding habit (WHO, 2016). However, studies have linked poor hand

hygiene practices of caregivers of children as one of the most common contributing factor of

diarrhea among children under five (Iroegbu, Ene-Obong, Uwaegute, &Amazigo, 2000)

(Mannan, & Rahman, 2011) (Pickering, Julian, Mamuya, Boehm, & Davis, 2011). Contaminated

hands have been largely implicated in the spread of a large number of foodborne disease

outbreaks; thus, the risk of foodborne diseases and associated ailments can be significantly

reduced by appropriate hand washing practices (WHO, 2016).

The major ways to prevent diarrhea include safe drinkable water; proper and enhanced

sanitation; good handwashing hygiene practices such as handwashing with soap and water,

exclusively breastfeeding a child from birth to the first six months, proper personal hygiene,

good food hygiene, health education about etiology and pathogenesis of the disease and rotavirus

vaccination. According to the World Health Organization Water for Health report 2001, it is

estimated that hand hygiene practices such as handwashing with soap and running water could

half the deaths associated with diarrheal disease (WHO, 2001). Another study in London

published by Lancet in 2003 also estimated that one million deaths associated with diarrhea

Golden Hands Program, 5

could be averted yearly if everyone routinely washed their hands (Curtis, & Camicross, 2003). A

randomized controlled trial executed in 16 primary schools using 6,000 students showed that

hand hygiene provided in the classroom reduced school absenteeism due to infection by 19.8

percent (Hammond, Ali, Fendler, Dolan, & Donovan, 2000). Study have shown that $3.35

invested in handwashing yields an equivalent health benefit as $11.00 invested in toilet

construction, a $200.00 spent in household water supply and thousands of dollars spent on

immunization (United Nations International Children's Emergency Fund (UNICEF), 2008). A

Cochrane review of 22 randomized controlled trials regarding the role of hand hygiene in

diarrhea prevention revealed that handwashing promotion in both rich and poor countries may

reduce the incidence of diarrhea by about 30 percent (Ejemot-Nwadiaro, Ehiri, Arikpo,

Meremikwu, & Critchley, 2015).

Golden Hands Program is therefore designed to reduce the problem of diarrhea-related

under-five mortalities by promoting handwashing hygiene among teachers, parents and children

through education on the best and most effective hand washing technique, importance and health

benefit of washing hand, how often hand washing should be done as well as providing running

taps inside and outside the classrooms through a pumped well system in Obafemi Awolowo

University (OAU) International Staff School, Nigeria.

Golden Hands Program, 6

GOLDEN HANDS PROGRAM PLANNING

The program planning model used for the Golden Hands Program is the MAP-IT

(Mobilize, Assess, Plan, Implement and Track) model. MAP-IT was chosen because it blends

both the community and evidence-based ideologies of health planning (Healthy People 2020,

2017). The MAP-IT model is ideal for the Golden Hands program because the “Mobilize”

section highlights the importance of identification, involvement, and formation of a coalition

with (1) stakeholders, specifically pharmaceutical industries and telecommunication industries

such as MTN and GLO; (2) partners specifically Osun State Ministry of Education and Ministry

of Health; (3) individuals; (4) community and religious leaders who are needed for the Golden

Hand program to be successful and sustainable. The MAP-IT phases are fairly similar to the

generalized program planning model, except for the Mobilize phase. This model was also chosen

because of the fluidity, flexibility, and functionality of its phases.

Constructs from two theories of health behavior - Social Cognitive Theory and Health

Belief Model will be employed as the theoretical basis of the Golden Hands program. The Social

Cognitive Theory constructs to be used will include self-efficacy, observational learning, and

facilitation/behavioral capability. All constructs from the Health Belief Model will be used.

The self-efficacy construct of Social Cognitive Theory was chosen because the theory

believes that increasing the confidence or belief in one's capability to carry out a given behavior

can help improve their health behavior (Bandura, 1977). Intervention components specifically

targeting ways to increase self-efficacy such as vicarious experience, mastery experience, verbal

persuasion, and improving physical and emotional state, will be used. This implies that

increasing the confidence of the school children on their ability to perform hand washing

regularly, will make them improve their hand washing habit. According to a longitudinal study

Golden Hands Program, 7

done to evaluate the effectiveness of short motivational and self-assisted handwashing

interventions, self-efficacy was found to be highly useful for the improvement of hand hygiene

practice (Lhakhang, Lippke, Knoll, & Schwarzer, 2015). Observational Learning was chosen

because this construct of social cognitive theory believes that a certain health behavior can be

improved by watching similar individuals or role models do the new task. This implies that the

handwashing habit of children can be improved by using their teachers and parents as role

models as well as educating them with an audiovisual content of children of similar age

performing the same handwashing behavior. The Facilitation/Behavioral Capability construct

was chosen because it deals with providing materials, resources, or changes in the environment

that facilitate the easy performance of new behaviors. This implies that training the children and

teachers on how to wash hands and the provision of running water in the school could improve

the uptake of hand washing behavior.

The Health Belief Model was chosen because it takes into account an individual’s

perception of possible barriers to health behavior change as well as their perception of threat

(Rosenstock, Irwin, 1974). The perceived threat (perceived susceptibility and perceived severity)

and perceived benefit constructs of this theory were chosen because it captures the role of

parents in maintaining handwashing habit in children. Children are likely to maintain their

handwashing behavior if their parents perceive they are threatened or see the benefit of hand

washing. Perceived barrier was chosen because the constructs believe that removal of barriers to

a particular health behavior will help improve the health behavior. This implies that provision of

running water and soap in school can help in the adoption of handwashing behavior. Cues to

action were chosen because the construct recognizes the role of external factors (such as parental

Golden Hands Program, 8

influence, posters, and signage) on individual perceptions, such as perceived benefits, and

perceived susceptibility.

GOLDEN HANDS PROGRAM INTERVENTION

Mission statement

The mission of the Golden Hands Program is to promote childhood well-being and

reduce diarrheal disease among preschool children of OAU international school in Nigeria

through hand washing hygiene practices.

Goal

To promote handwashing hygiene practices among preschool children of OAU

international school in Nigeria through hand washing hygiene practices.

Objectives

Prior to the commencement of the Golden Hands Program, teachers of OAU International

Staff School will deliver a program advertisement and notification letters to the preschool

children and their parents in the month preceding the program commencement.

By the end of the Golden Hands Program, 50 percent of the participants will be able to

demonstrate the techniques of hand washing, mention three benefits of hand washing hygiene

and identify one germ that causes diarrheal disease among the pupils.

Within three months of the start of the Golden Hands Program, at least 50 percent of the

preschool children will demonstrate hand washing before a meal and after using the bathroom

every day in the school.

Golden Hands Program, 9

Within three months of the start of the Golden Hands Program, at least 50 percent of the

parents of the preschool children will report their children demonstrate handwashing at home

daily after arriving from school, before a meal and after using the bathroom.

Within six months of the start of Golden Hands Program, there will be 50 percent

reduction in the passage of loose watery stool among the preschool children.

Golden Hands Program will be implemented as an after-school program that will meet

thrice weekly from 12:00 noon to 1:00 pm (during school lunch break) for eight weeks. It will

take place at the OAU international staff school, Ile-Ife, Osun State Nigeria. Facilities needed

include school learning facilities such as classroom, stereo equipment, projector and projector

screen, borehole water and running taps as well as handwashing equipment (handwashing basin,

paper towels, and trash bins).

Prior to implementation, there will be the installation of a borehole running water system

that will include three handwashing basins in the three classes of preschool children at OAU

International Staff School. STC will engage in a social marketing campaign for Golden Hands

Program prior to the kick off date. Each preschool child will go home with a flier to share with

parents. Posters and fliers will be posted throughout the school, OAU campus, grocery stores,

town halls, churches, mosques and the staff quarters recreation centers. A Facebook and web

page advertisement will be set up. A bulk short message service (SMS) will be sent to all parents

and guardians of the preschool children. Television and radio commercials will be made.

Newspaper advertisement will also be done in four national and local newspaper publications.

Marketing the program will begin six weeks before the commencement of the program.

Golden Hands Program, 10

The Golden Hands Program will embark on the training of the personnel that will partake

in the implementation. The teachers, medical student volunteers, the Community Health

Education Specialist and the STC team will meet for two weeks prior to the Golden Hands kick

off day. This meeting will be held three times in a week on Monday, Wednesday, and Friday

during the lunch break of the school at one of the preschool classroom. In this training, the

facilitators will be trained and strategize on the implementation of the Golden Hands Program.

The teachers will be given logbooks, which they will use to assess the performance of the

children during and after implementation of Golden Hands. The handwashing practices of the

children will be recorded in the school every day using the logbook and the record of the stool

frequency will be recorded using the Bristol Stool count (Bristol stool scale, 2017). The teachers

will also be instructed to give a copy of the logbook to each pupil for their parents to use to

assess them at home and bring to school every Monday for a review.

Golden Hands Program will kick off with an opening ceremony. Important dignitaries

will be invited to the opening ceremony. In this ceremony, there will be an official

commissioning of the Golden Hands borehole pipe-borne water system by the executive

governor of Osun State, Nigeria. There will be a keynote address by the Honorable Minister of

Health, Federal Republic of Nigeria. This will address the theme of the program which is

‘making the children germ free’. All members of the public will be invited to the Golden Hands

Program opening ceremony. The royal father of the day will be His Royal Majesty, the Ooni of

Ile-Ife, Oba Ogunlesi. The vice-chancellor of OAU will be among the dignitaries. Golden Hands

T-shirt will be distributed to all attendee of the opening ceremony.

The Golden Hands Program session will meet three times a week for one hour during the

school lunch hour. The days of the week chosen will be Tuesday/Wednesday/Thursday. Each

Golden Hands Program, 11

meeting session will have a different song and rhyme composed to address the teaching for the

day. The songs and rhymes will have both an English and Yoruba language version. Golden

Hands education segment will last for 30 minutes. Only the preschool children within the age of

three and five years will be selected for the program. During the Golden Hands Program,

participants will be served fruit and water. Four different fruits will be taken throughout the

program. These fruits are Mango, Guava, Apple and Cashew. One fruit will be taken for each

week and the washing of the fruits will be demonstrated and practiced throughout the program.

Hand washing after eating the fruits will be demonstrated and practiced. This is aimed at

enabling the children to master the hand washing behavior.

The first day of the Golden Hand Program, there will be a general introduction to the

Golden Hands Program and an overview of the activities. The children will watch a cartoon

video on hand washing demonstrated by children of their age downloaded from YouTube. The

first day of contact in each week will be for the recall of previous lessons and to watch a video

during the education segment. After the education segment, the children will take the fruit of the

week and demonstrate handwashing and fruits washing. The second day of the program will be a

short lesson on benefits of handwashing hygiene. Three benefits will be taught throughout the

program. Each benefit will be discussed on every second meeting day in the week. One song will

be learned about the benefit discussed for the day. This education session will be followed by the

fruit of the week session where the children will wash their hands and their fruits. The third day

of the program will be for teaching about the germs that cause watery stool. Three germs will be

considered. One germ will be learned each week and a rhyme will be memorized about the germ

and its prevention. this will be followed by the fruits of the week session. A handwashing

demonstration will be done each day with an emphasis on routine hand washing before a meal,

Golden Hands Program, 12

after using the bathroom and following arrival at home. The teachers will be encouraged to sing

the songs learned in class every day, and a daily class recitation of the rhyme will be done.

The timeline for the Golden Hands Program stretches over 30 weeks beginning with the

program rationale development during the initial four weeks. Needs assessment and development

of goals and objectives are allotted three weeks and two weeks respectively in the timeline. The

formation of the intervention, along with a gathering of resources will take four weeks. The

marketing of the program will take place from week six through week nine (four weeks’

duration). The Golden Hands program will kick off in the 10th week with a pilot study lasting

through the 17th week (eight weeks’ duration). During this time, weekly participation data will be

collected for the eight weeks’ period. Performance and mastery of the program will be assessed

and documented. The remaining weeks after the program will be used for evaluation of the

program to see the impact of the Golden Hands Program. Data of frequency of diarrhea will be

collected throughout during and after the Golden Hands Program using the Bristol Stool Chart

(Bristol stool chart, 2017). Data collected will be carefully analyzed at the end of the program

and the information gathered will be presented to the stakeholders. The Golden Hand Program

data and feedback will be used for program readjustment in the future and plan for the

subsequent phase of the program. Table two shows a detailed timeline.

The Golden Hands Program will need a lot of both human and non-human resources for

its implementation. The human resources needed are three preschool teachers to monitor the

participants, 10 medical students in community medicine rotation to serve as volunteers and

work with the facilitators, three community health education specialists to deliver health

education on hand washing hygiene. The education resources will be gathered from free

resources such as kidshealth.org, youtube.com/watch v, and www.partselect.com/handwashfor

Golden Hands Program, 13

kids. These materials were chosen because they are free, reliable and appropriate for educating

preschool children. A classroom for preschool will be used as the space for this program. There

are three classrooms for preschool children in OAU international staff school and one of the

classrooms will be used. The classroom chosen for the program demonstration will be the one

with good electricity connection but the handwashing basin will be installed in all three

classrooms. The school management will give approval for use of the classroom and adopt the

program at no cost. The Golden Hands program will be held at the Oduduwa Multipurpose Hall

located inside OAU campus at no cost. All these details were negotiated with the State Ministry

of Education and Management of OAU international school. Table three shows clearly all

equipment and supplies that need to be purchased. The school will provide the space for

construction of borehole water supply plant and the plumbing work, while the Golden Hands

Program facilitators will purchase the materials needed and pay for the construction from the

grant fund. Other items needed include promotion materials (T-shirts and logoed reusable water

bottles), projector and projector screen, HP laptop to be connected to the projector, electronic

tablets for facilitators for note taking in the field and logbooks, and stool scale for the

participants’ diarrhea tracking. All these will be purchased with the grant funds.

Golden Hands Program is an eight-week program focusing on promoting hand washing

hygiene practices. The majority of the $15,000 grant will be centered on the construction of

borehole, running of pipe-borne water supply and plumbing works, transportation, food,

supplies, and marketing materials for the program. Donations of fruits from the OAU community

farmers and bottled water from OAU water bottling company will help take care of some of the

costs. Only the community health education specialist will be paid $10 per hour for their services

throughout the 8 weeks. All activities will be done within the school premises. The STC team

Golden Hands Program, 14

will ensure that the grant money is judiciously spent for the preschool children and school health

promotion. See table 3 for the detailed budget.

GOLDEN HANDS PROGRAM EVALUATION PLAN

The purpose of evaluation is to determine the value, worth, efficacy, or effectiveness of a

program. Evaluation of the Golden Hands Program will aid program planners to ensure that the

program objectives are met and to determine if any possible changes are needed in the future.

Five types of evaluation – formative, process, impact, summative and outcome evaluations - will

be done by the STC team. Members of this team are Chukwuebuka Ogwo, and Stephen

Ayosanmi.

The Golden Hands Program will be implemented in the OAU International School in

Nigeria as an after-school program that meets thrice in a week from 12:00 noon to 1:00 pm

(during school lunch break) for eight weeks and provide hand hygiene education to preschool

children between the age three to five. Due to the high burden of diarrheal diseases in Nigeria,

the Golden Hands Program was developed with the aim of reducing diarrheal disease among

preschool children of OAU International School in Nigeria through the promotion of

handwashing hygiene practices. OAU International School in Nigeria was specifically chosen for

Golden Hands Program because a study revealed that over one-third (37percent) of under 5

children in this environment suffer from diarrhea (Okeke, Lamikanra, Steinruck, & Kaper,

2000), and also because the school is easily accessible with normally distributed

sociodemographic features.

The Golden Hands Program intends to achieve the goal through these objectives: (1)

Prior to the commencement of the Golden Hands Program, teachers of OAU International Staff

Golden Hands Program, 15

School will deliver a program advertisement and notification letters to the preschool children and

their parents in the month before the program commencement. (2) At the end of the Golden

Hands Program, 50 percent of the participants will be able to demonstrate the techniques of hand

washing, mention 3 benefits of hand washing hygiene and identify one germ that causes

diarrheal disease among the pupils. (3) Within first three months of the start of the Golden Hands

Program, at least 50 percent of the preschool children will demonstrate hand washing before a

meal and after using the bathroom every day in the school. (4) Within three months of the start of

the Golden Hands Program, at least 50 percent of the parents of the preschool children will

report their children demonstrate handwashing at home daily after arriving from school, before a

meal and after using the bathroom. (5) Within six months of the start of the Golden Hands

Program, there will be 50 percent reduction in the passage of loose watery stool among the

preschool children.

Several resources will be needed to implement the Golden Hands Program. These include

personnel, educational materials, pipe borne water equipment and infrastructures. The personnel

involved are three preschool teachers to monitor the participants, 10 volunteer medical students

in community medicine rotation whom will work with the facilitators, three community health

education specialists to deliver health education on handwashing hygiene. The educational

resources will be gathered from free and reliable resources such as kidshealth.org,

youtube.com/watch v, and www.partselect.com/handwashfor kids.

The stakeholders for the Golden Hands Program will include: (1) OAU international

school administration, (2) the Save the Children Team, (3) the preschool teachers and volunteer

workers, (4) three community health education specialists, (5) the funding body, (6) the major

businesses/companies that made donations to the program. Depending on the stakeholders’ role,

Golden Hands Program, 16

each stakeholder can choose to evaluate the program differently. The Golden Hands Program is

following the recommendations of the Logic model (Alter, Egan, 1997).

OAU International School administration will be involved in (1) contractual agreements,

in which OAU International School administration highlight the things they want the program

planning committee to evaluate, how they want the data collection to be done. The

administration will also include how they want the data collected to be analyzed, and presented,

ensure legal and ethical process is followed in reporting, and the evaluation protocols are

followed judiciously; (2) formative evaluation, where program planners will use OAU

international school administration’s input to assure that the Golden Hands Program use

realizable methods in meeting the children’s needs and accounting for what was done; (3)

process evaluation, in which they assess if all the adequate procedure were followed; (4) impact

evaluation, where it will use the short-term findings of the Golden Hands program to check if the

program served the correct target population and if participants’ needs were met; (5) summative

evaluation, where they will utilize findings from the program to determine if is achieving its

goals; (6) Outcome evaluation, where they will be required to say their views regarding the best

ways to sustain the program, as well as receive an end report of the program. This method of

evaluation will lure the OAU International School administration to get involved because they

share in both the success and failure of this program.

Program planning committee will be responsible for the program evaluation via the

following: (1) contractual agreements, where all the details are spelt out especially with regards

to operational modalities; (2) formative evaluation, where the sources for already existing

programs are checked which can be used as template for Golden Hands Program, formulate work

plan and budget; (4) process evaluation, where by members will take notes and keep an

Golden Hands Program, 17

inventory of events, setbacks, expenses, other activities; (5) impact evaluation, in which the

views of each member is collected to know what is going well, what is to be changed; (6)

summative evaluation, to measure effects of the Golden Hands Program on participants to check

any possible changes, whether program strategies need to be altered, to organize reports, and to

make comparison with other related programs; (7) outcome evaluation, where every member of

the committee will be required to say something about the sustainability and long-term goal of

the program, what possible changes should be made for the next cycle of implementation. The

outcome and process evaluation will involve mostly the pre-school teachers and volunteers. We

will ask for their input on ways to fortify the program, track the progress of events, setbacks and

costs as well as measure their opinion on what needs to be changed. An evaluation report and

progress report from the pre-school teachers and volunteers will be obtained during the staff

training weekly. At the end of the program, the evaluation report will be discussed with this

group. The participant’s parents of children who are part of the program will receive a final

report (outcomes evaluation) of the program.

According to the grant requirements, there is a need to submit evaluation reports to the

funding/grant awarding agency. The evaluation reports will include (1) formative evaluation,

within which results obtained will be used to support the funding requests for Golden Hands

program; (2) process evaluation, within which the progress report of the program in terms of

logistics will be presented to them; (3) impact evaluation, where they will receive results

regarding the short-term progress of the program; (4) outcome evaluation, where they will

receive a long term result and final evaluation of the Golden Hands Program success and

significance. The program donors like businesses, organizations or individuals will be involved

in process and impact evaluations, where the results regarding the progress of the program and

Golden Hands Program, 18

short-term impact on participants will be shared with them. Donations will be solicited by

sending out solicitation letters and, then a gratitude letter attached to the results of the

evaluations.

The process, impact, and outcome evaluations are the three evaluations that will be done.

These evaluations were chosen because they (1) agree with the MAP-IT planning model which

was used for Golden Hands Program, (2) help in evaluating the objectives, the short, medium

and long-term Golden Hands Program outcomes, and (3) offer information regarding likely

implementation changes needed in the future. For instance, a process evaluation will show if

hand hygiene education was delivered as designed and intended. Not following the protocol may

affect the overall sustainability and effectiveness of Golden Hands Program. The impact

evaluation will be used to measure any short-term/immediate changes in handwashing habit that

might have occurred as a result of the Golden Hands Program. Outcome evaluation will be used

to determine the long-term impact of Golden Hands Program on diarrhea reduction,

improvement in the quality of life, and to measure if hand washing behavior will be sustained

over time.

Conventional approach and participatory approaches will be used for the Golden Hands

Program. The participatory approach will be used for process evaluation, while the impact and

outcome evaluation will be done using conventional approach. The participatory approach was

chosen because Golden Hands Program planners would like volunteers, teachers, participants,

and everyone directly involved in the Golden Hands Program to participate and give their input

in order to improve the program. The conventional approach for impact and outcome evaluation

was chosen because only facilitators are allowed access to the data and have obtained training in

Golden Hands Program, 19

research and data analysis, and the funders require this type of evaluation for the analysis of final

outcome.

Golden Hands Program will use a non-experimental (pre-test/post-test) design. This was

chosen due to lack of control group or randomization and because of the rigors and cost

associated with experimental studies. The data for impact evaluation of the Golden Hands

program will be collected using a performance chart held and recorded by both the teacher and

parents of the child. The teacher will tick a box each time a child washes his/her hand in school

and the parents will do same at home if the child performs a hand washing activity before and

after eating or playing. The data collected will be analyzed descriptively to show the frequency

of hand washing behavior. Data for outcome evaluation will be collected using the Bristol Stool

Chart by both parents and teachers of this preschool children. The data collection will focus on

presence, absence, and frequency of diarrheal stool by the children. Each parent, as well as the

teacher, will have a chart where they will record the frequency, and consistency of the stool

passed by each child within the timeframe of this study.

SPSS version 23 will be used to analyze all the data collected from this study. Firstly, a

descriptive analysis of the hand washing frequency will be done, then parametric tests like t-test

will be done to compare the continuous dependent variable (diarrheal outcome) and a categorical

independent variable (sex and socioeconomic status). ANOVA test will be done to compare the

difference in a group of more than one categorical independent variables on one dependent

variable. Pearson’s correlation tests will be done check for any association between the

continuous independent variables (age) and the continuous dependent variable (diarrheal

outcome). Multiple logistic regression analysis will be done to ascertain the effect of multiple

factors on the outcome of diarrhea, to eliminate possible confounders, calculate odds ratio at 95

Golden Hands Program, 20

percent confidence interval and to check the interaction between handwashing frequency and

diarrhea outcome. The analysis will be done by the planning committee and in the case of any

analytical issues, a statistician friend will be consulted. To ensure the accuracy and quality of the

data, data will be recorded by two trained individuals before analysis.

Confidentiality of the participants will be maintained by restricting access to the data

collection sheet to committee members only. Each participant will be de-identified by replacing

their names with a code. The master sheet containing the raw data will be kept in a locked file

cabinet in an office and if entered electronically, data files and the computer will be password

protected. All members of the Golden Hands Program planning committee will partake in the

evaluation process and weekly data collection. The results obtained will be discussed at weekly

at the committee meetings and if data suggests that changes are needed, the decision will be

made by the planning committee based on a majority vote. Results will be presented to the

stakeholders through PowerPoint presentations during the biweekly volunteer and committee

meetings. Parents will receive a written report upon completion of the evaluation, and final

report and evaluation will be presented to the OAU international school administration and the

donor agency. Every feedback received from stakeholders will be reflected upon and considered

by the STC team for the future Golden Hands Programs.

Golden Hands Program, 21

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Golden Hands Program, 25

APPENDICES

Table 1- DETAILED IMPLEMENTATION PLAN FOR GOLDEN HANDS PROGRAM

Table 2- PROJECTED BUDGET FOR GOLDEN HANDS PROGRAM

Table 3- TIMELINE FOR GOLDEN HANDS PROGRAM

Logic model

Program poster

Bristol stool scale

Logoed water bottle

Logoed T-shirt

Golden Hands Program, 26

Table 1: DETAILED IMPLEMENTATION PLAN FOR GOLDEN HANDS PROGRAM

DAY 1 DAY 2 DAY 3

WEEK

1-2

1. Introductory activities - 30

minutes

• Introduce Golden Hands

Program to preschool children

• Teach the children the Golden

Hands Program anthem

• Watch video of handwashing

demonstration for kids

2. Demonstration and snacks - 30

minutes

• Handwashing techniques

demonstration.

• Apple fruits will be given to

participants and washing of

the fruits demonstrated.

1. Education and rhyme - 30

minutes

• Learn about one of the

benefits of hand washing

• Learn songs about one

benefit of hand washing

2. Demonstration and snacks -

30 minutes

• Health educators and

teachers demonstrate hand

washing and help pupils

wash their fruit (apple).

1. Education and rhyme - 30

minutes

Learn about one of the germs

causing watery stool

Learn rhyme on the one germ

prevention

2. Demonstration and snacks -

30 minutes

• Health educators and class

teachers demonstrate hand

washing and ask pupils to

wash their fruits before

eating.

WEEK

3-4

1. Education and rhyme - 30

minutes

• Recap last week lessons,

rhyme, and songs.

1. Education and rhyme - 30

minutes

• Learn the 2nd benefit of hand

washing.

1. Education and rhyme - 30

minutes

• Learn about the 2nd germ

causing watery stool

Golden Hands Program, 27

• Sing and recite rhyme

learned previous week.

• Reward good recap and

participation of preschool.

children.

• Watch video of hand

washing demonstration for

kids.

2. Demonstration and snacks- 30

minutes.

• Health educators and class

teachers help pupils watch their

hands.

• Cashew fruits provided as

snacks and fruits washing

demonstrated.

• Learn songs about the 2nd

benefit of hand washing.

2. Demonstration and snacks -

30 minutes

• Health educators and class

teachers assist pupils to

watch their hands.

• Fruits (cashew) provided as

snacks and fruits washing

demonstrated.

• Learn rhyme on the germ

prevention

2. Demonstration and snacks- 30

minutes

• Health educators and class

teachers assist pupils to

wash their hands and

observe pupils watch their

fruits (cashew) before

eating.

WEEK

5-6

1. Education and rhyme - 30

minutes

• Recap last week lessons, rhyme,

and songs.

• Sing and recite rhyme learned

previous week.

1. Education and rhyme - 30

minutes.

• Learn the 3rd benefit of hand

washing.

• Learn songs about the 3rd

benefit of hand washing.

1. Education and rhyme - 30

minutes.

• learn about the 3rd germ

causing watery stool

• learn rhyme on the germ

prevention

Golden Hands Program, 28

• Reward good recap and

participation of preschool

children.

• Watch video of hand washing

demonstration for kids.

2. Demonstration and snacks - 30

minutes

• Mango fruits provided as snacks

and fruits washing

demonstrated.

• Health educators observe pupils

washing their hands.

2. Demonstration and snacks -

30 minutes

• Mango fruits provided as

snacks and fruits washing

demonstrated.

• Health educators observe

pupils washing their hands.

2. Demonstration and snacks -

30 minutes

• Mango fruits provided as

snacks and fruits washing

demonstrated.

• Health educators observe

pupils washing their hands.

WEEK

7-8

1. Education and rhyme - 30

minutes

• Recap last week lessons, rhyme,

and songs.

• Sing and recite rhyme learned

previous week.

• Reward good recap and

participation of preschool

children.

1. Education and rhyme - 30

minutes

• Recall about the three

benefits of hand washing

• Recall on the songs about

the three benefits of hand

washing

2. Demonstration and snacks -

30 minutes

1. Education and rhyme - 30

minutes

• Recall of the three germs

causing watery stools

• Recall rhyme about the three

germs learned previously.

2. Demonstration and snacks -

30 minutes

Golden Hands Program, 29

2. Demonstration and snacks - 30

minutes

• Guava fruits provided as snacks

and fruits washing

demonstrated.

• Health educators observe pupils

washing their hands and fruits.

• Guava fruits provided as

snacks and fruits washing

demonstrated.

• Health educators observe

pupils washing their hands

and fruits.

• Assessment and evaluation

of children

• Guava fruits provided as

snacks and fruits washing

demonstrated.

• Health educators observe

pupils washing their hands

and fruits.

• Assessment and evaluation.

Golden Hands Program, 30

TABLE 3: PROJECTED BUDGET FOR GOLDEN HANDS PROGRAM

REVENUE AND SUPPORT

Contributions from sponsors:

FRUITS 800 pieces of Mango

800 pieces of Apples

800 pieces of Guava

800 pieces of Cashew

Grants $15,000

Expenditures

Supplies:

Borehole drilling 1 X $2,000 $2000

Plumbing materials and works 1 X $2000 $2000

Projector and projector screens 1 X $500 $500

Golden Hand Logoed Reusable water

bottle

100 X $4 $400

T-shirts 1000 X $5 $5000

Golden Hands Program, 31

Golden Hands Program kick-off

ceremony

TV advertisement

Press release

Newspaper advert

Radio jingle

Golden Hands Program snacks

2 X $100

4 X$50

4 X $100

1 X $100

500 X $20

$200

$200

$400

$100

$1000

Hp laptop 1 X $500 $500

SPSS version 23 1 X $100 (student pack for

12 months)

$100

Samsung tablet 4 X $150 $600

Remunerations for three Community

Health Specialist

$8.25 (per hour) X 3 hours a

week for 8 weeks

$600

Printing

Brochures, flyers, posters $1000

Log book 80 X $4.5 $400

Total expenses $15,000.00

Golden Hands Program, 32

Golden Hands Program, 33

Golden Hands Program, 34

Golden Hands Program, 35

Golden Hands Program, 36

TABLE 2: TIMELINE FOR GOLDEN HANDS PROGRAM

TASKS WEEKS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Development of

program rationale

X X X X

Conduct need

assessment

X X X

Development of

Golden Hands

Program goals and

objectives

X X

Formulation of

interventions

X X X X

Formative evaluation X X X X X X X X X X X X X

Golden Hands Program, 37

Collection of useful

resources

X X X X

Installation of

borehole and running

water

X X X X

Staff and volunteer

training

X X

Social marketing of

Golden Hands

Program

X X X X X

Golden Hands

Program

Kickoff/opening

ceremony

X

Data collection X X X X X X X X X

Golden Hands Program, 38

Summative

evaluation

X X X X X X X X X X X X X X

Analysis of collected

Data

X X X X

Adjust program X X X X

Present results to

stakeholders

X X X

Plan for next phase

of the program

X X X

Continue with

follow-up for long-

term evaluation

X X X X X X X X X X

Golden Hands Program, 39

Golden Hands Program Logic Model

Inputs

Outputs Outcomes -- Impact

Activities Participation Short Medium Long

• Staff

• Three Community

health workers

• Volunteers (10

Medical students)

• Money ($15,000)

• Fruits

• Golden hands

Program T-shirt

• Golden hands

Program water

bottle

• Social Marketing with posters, fliers,

and media advert.

• Golden Hands Program Free T-shirt

distribution.

• Opening ceremony

• Borehole and handwashing basin

installation

Education and rhyme

• Learn songs and rhyme of hand washing

• Watch video of hand washing

demonstration for kids

Demonstration and snacks

• Health educators demonstrate hand

washing and help pupils wash their

fruits

• 30 Preschool

Children

• Three Teachers

• OAU

international

school

administration

• 10 Volunteer

medical students

• Funding agency

• Ministry of

Education

• Save the

Children (STC)

Team

• Increased hand washing

hygiene practices.

• Increased self-efficacy.

• Increased knowledge of

health merits and

demerits of hand

washing.

• Increased awareness hand

washing hygiene.

• Improved hand washing

skills.

• Increased desire to

change and improve hand

washing habit.

• Reduction in the

incidence of

diarrhea.

• Improvement in

daily hand washing

habit.

• Reduction in school

absenteeism due to

diarrhea-related

disease.

• Adoption of the hand

washing habit.

• Decrease diarrhea-

associated morbidity and

mortality.

• Increased quality of life of

preschool children.

• Reduction in

hospitalization from

diarrhea related cause.

• Reduction in cost

associated with treatment

of diarrhea

Assumptions

External Factors

The intervention was widely accepted by both the children and school administration. The program was

properly funded and funds were used judiciously.

Environmental factors like insecurity, lack of clean water at home and within the community; the

parental level of education and involvement.