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Game-based curriculum improves handwashing practice among primary school children in Ghana

February 15, 2018

Game-based curriculum improves handwashing practice among primary school children in Ghana

By Mary Beth Dawson

Diarrheal diseases and acute respiratory infections are the top two causes of death in children-under-five worldwide. In 2015, about 10,000 children-under-five died in Ghana from these causes.[1] Handwashing with soap and water can reduce the risk of acute respiratory infections by 6 to 44% and diarrheal diseases by about 30%, yet according to a 2014 National Demographic and Health Survey, only 39% of households in Ghana had water and soap. [2–4]

Handwashing with Ananse is a game-based curriculum that teaches primary school children in Ghana how, when, and why to wash their hands with soap and water. The curriculum has children listen to three stories of a traditional character from Ghanaian folklore, Ananse the Spider, who has hidden all the handwashing knowledge in the world in his pockets. Children play hygiene games based on the stories, practice handwashing with soap, and teach others what they’ve learned to “break” Ananse’s pockets and release the handwashing knowledge back into the world. The Engagement Lab partnered with the Ghanaian Red Cross Society, Right to Play Ghana, Red Cross Red Crescent Climate Centre, Ghana Educational Service, and several children in Ghana to design Handwashing with Ananse in 2015.

Ananse is a trickster character from traditional Ghanaian folklore. In Handwashing with Ananse, Ananse has hidden all of the handwashing knowledge in the world in his pockets.

Based on initial excitement around Handwashing with Ananse, UNICEF Ghana funded an evaluation to determine whether the curriculum was effective in improving knowledge of how, when, and why to wash hands with soap; generating favorable attitudes toward handwashing with soap; and increase handwashing behavior among children who participated. Researchers evaluated the curriculum with 20 primary schools (10 urban, 10 rural schools) from two districts in Central Ghana and one district in Eastern Ghana. All schools received soap and Tippy Tap handwashing stations over the study period. Ten schools participated in Handwashing with Ananse and 10 comparison schools did not receive the curriculum. Children’s knowledge, attitudes, and behaviors were measured at baseline, two weeks after the curriculum ended, and 15 weeks after the curriculum ended in several ways:

  • Surveys with children randomly selected from each age group

  • Structured observations of children’s handwashing behavior at Tippy Taps

  • Structured observations of the curriculum being implemented

  • Soap use measurements

  • Video observations of Tippy Taps

  • Focus groups in schools that participated in Handwashing with Ananse

Children participate in Handwashing with Ananse games during a training with facilitators in March 2016.

> > The study showed a significantly higher increase in knowledge of how to wash hands with soap among children who participated in Handwashing with Ananse.

The study showed a significantly higher increase in knowledge of how to wash hands with soap among children who participated in Handwashing with Ananse. Knowledge of why and when to wash hands with soap was very high at baseline and did not increase significantly. Handwashing with Ananse also motivated children to talk about handwashing with their friends and family significantly more than children in the control group. Surveys, Tippy Tap observations, soap measurements, and video observations all showed a significantly higher increase in handwashing behavior for children who participated in Handwashing with Ananse than in the control group that received only handwashing infrastructure. Self-reported illness dropped in both the intervention and control groups, but it significantly dropped by 8.2% more in the intervention group that received Handwashing with Ananse 15 weeks after the curriculum ended.

The evaluation provides evidence that Handwashing with Ananse is effective in shifting handwashing knowledge, attitudes, and behaviors among primary school age children. Handwashing with Ananse is being considered by the Ghana Educational Service for wider implementation and integration into the primary school curriculum in Ghana.

To learn more about Handwashing with Ananse, download the curriculum materials, and read a full report on its evaluation here.

¹ World Health Organization. WHO GAPPD Indicators [Internet]. Monitoring Progress in Averting Pneumonia and Diarrhoea Deaths. [cited 2017 Oct 31]. Available from: http://www.who.int/test/others/gappd/#

² Rabie T, Curtis V. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health. 2006 Mar 1;11(3):258–67.

³ Ejemot-Nwadiaro, Regina I, Ehiri, John E, Arikpo, Dachi, Meremikwu, Martin M, Critchley, Julia A. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst Rev [Internet]. 2015 Sep [cited 2017 Oct 31];9(CD004265). Available from http://onlinelibrary.wiley.com.ezproxy.bu.edu/doi/10.1002/14651858.CD004265.pub3/full

⁴ Ghana Statistical Service, Ghana Health Service, ICF International. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, ICF; 2015 Oct.

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