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Knowledge, Aptitude, Behaviour and Practices among school children in India

Rajasthan, Andhra Pradesh, Maharashtra, Uttar Pradesh, Bihar, and Telangana

Technical Paper

Written By: Nitish Kapoor, Sr. Vice President, RB

Co -Authors: Ravi Bhatnagar, Manager External Affairs, RBVipin Yadav, CEO, Dure Technologies Pvt. Ltd.Subash Ghosh, Public Health Expert, Dure Technologies Pvt. Ltd.

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Synopsis

In the Knowledge, Attitude, Behaviour and Practices (KABP) study on

hygiene among children in schools, school heads, teachers and students were

interviewed in six states across majority public schools and few private schools.

This paper is based on the findings from the baseline study.

There was a state wise variation in socio-demographic profile of children

and their families across the six states i.e. Bihar, Maharashtra, Andhra Pradesh,

Telangana, Rajasthan and Uttar Pradesh. In Rajasthan, 45% of the schools

visited were private schools; the differences in practices were apparent.

Parents in Maharashtra were reported to be most educated. Higher education

level among parents of Maharashtra seems to translate into better perception

among children about portable drinking water. Television was widely available

in homes and its use was widespread across all the states. Mobile phone use

was also trickling down to the younger population, but the access to internet

was sparse and limited. At the same time it was found that presence of

television at home has little to do with the knowledge and practice of hygiene.

Sources of drinking water at school and at home were found to be same

within a particular state. 19% children reported using tubewell/borewell water

across all the states. Around 35% schools use hand pump and 8% use public

tap/standpipe. In Bihar and Uttar Pradesh, handpump was the most common

source whereas in Rajasthan and Andhra Pradesh, tubewell was the dominant

source of water. Schools where water was available in the premises, the water

sources was generally located within 500 meters from the school.

Students reported availability of flush toilets at school and they also

think that number of toilets in the school was sufficient. Teachers emphasise

the need of improving cleanliness of the toilets and also increase in number of

toilets at school as children, particularly boys urinate in open fields of the

school. Children reported presence of separate toilet in school for girls, but

not all the schools across all six had that. Presence of separate toilet for

differently abled was almost negligible. 39% of children reported presence of

toilets at home. But the usage of toilets was challenge that needs to be

addressed. High number of children across age and gender reported open

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defecation. As a result of which, children feel scared both during day and night

time to defecate.

There was a need to improve knowledge about hand washing especially

during illnesses. There were state wise variation, but none of the students of a

particular state were found to be more aware than the other.

Use of sanitary napkins by girls during menstruation varies across

states. Maharashtra and Uttar Pradesh reported highest use of sanitary

napkins, whereas Andhra Pradesh reported high use of cloth (41%) as

absorbent.

It was found that children were generally aware that not practicing

adequate hygiene can cause diseases and spread them too. Children do

understand the importance of handwashing at critical moments but practices

was limited. There is an urgent need to spread the awareness of handwashing

and inculcate the practice. Educators believe that this can be imparted to them

as part of the curriculum and peer effects also play an important role.

Education and behaviour change programs need to be integrated in children’s

education plans and need to be taught through activity based lessons.

Introduction

In developing countries like India, poor hygiene and sanitation practices

especially among children increases the burden of communicable diseases.

The root cause of many problems can be associated with water. Many women

and girls spends hours in fetching water from far away. Sanitation is also as

basic as need as food. Toilet near home provides safety privacy and dignity to

women and children. This paper is from a study that evaluates the knowledge,

attitudes, behaviour and practices (KABP) of hygiene among school going

children in rural areas of six states in India namely Rajasthan, Telangana, Uttar

Pradesh, Bihar, Maharashtra and Andhra Pradesh. The paper assessed the

extent to which proper knowledge and awareness about hygiene is associated

with personal hygiene practises by young children and their families.

Poor hygiene is directly correlated with poor health and illnesses. It is

the primary factor that causes and spreads communicable diseases. According

to Curtis et al (2009), “62% and 31% of all deaths in Africa and Southeast Asia,

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respectively, are caused by infectious diseases”. According to Spears (2012),

“construction of total Sanitation Campaign latrines is associated with a decline

in rural infant mortality. On an average the mean infant mortality rate was

decreased by 4 per 1000 and average height increased by 0.2 standard

deviation after proper sanitation facility is provided.”

“Children with handwashing practices are less likely to report

gastrointestinal and respiratory symptoms (Vivas, 2010). In a study conducted

by Bussena and Snehalata in Gargeyapuram village, Kurnool district of Andhra

Pradesh (1999), “caste plays a very important role in toilet and tap connection

at homes as income distribution in rural India is highly skewed towards a

particular caste group. Also most of SCs and STs take bath once in a week,

partly because of unavailability of water and partly because of their lack of

knowledge. Also most of them washes hand without using any material.”

According to Unicef, rates of handwashing are low across the world.

Lack of soap cannot be seen as a barrier as presence of soap has been

reported in the rural setting for washing clothes, utensils and self. The practice

of using soap for handwashing needs to be promoted effectively.

“Handwashing at critical moments including before eating or preparing food

and using the toilet can reduce diarrhea rates by more than 40%.” As per

Unicef, “new studies suggest that handwashing promotion in schools can play

a role in reducing absenteeism among primary school children. In China, for

example, promotion and distribution of soap in primary schools resulted in 54

per cent fewer days of absence among students compared to schools without

such an intervention.”

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Exhibit 1: FACTS AND FIGURES FROM UNICEF

● Over 1.5 million children under five die each year as a result of diarrhoea. It is the second most common cause of child deaths worldwide.

● Handwashing with soap at critical times - including before eating or preparing food and after using the toilet - can reduce diarrhoea rates by more than 40 per cent.

● Handwashing with soap can reduce the incidence of acute respiratory infections (ARI’s) by around 23 per cent.

● Pneumonia, is the number one cause of mortality among children under five years old, taking the lives of an estimated 1.8 million children per year.

● Hand Washing can be a critical measure in controlling pandemic outbreaks of respiratory infections. Several studies carried out during the 2006 outbreak of severe acute respiratory syndrome (SARS) suggest that washing hands more than 10 times a day can cut the spread of the respiratory virus by 55 per cent.

● Handwashing with soap has been cited as one of the most cost-effective interventions to prevent diarrhoeal related deaths and disease.

● A review of several studies shows that handwashing in institutions such as primary schools and daycare centers reduce the incidence of diarrhoea by an average of 30 per cent.

● Rates of handwashing around the world are low. Observed rates of handwashing with soap at critical moments – i.e, before handling food and after using the toilet - range from zero per cent to 34 per cent.

● A study shows that handwashing with soap by birth attendants and mothers significantly increased newborn survival rates by up to 44 per cent.

● Water alone is not enough; yet soap is rarely used for handwashing. The lack of soap is not a significant barrier to handwashing – with the vast majority of even poor households having soap. Soap was present in 95 per cent of households in Uganda, 97 per cent of households in Kenya and 100 per cent of households in Peru. Laundry, bathing and washing dishes are seen as the priorities for soap use.

“Hygiene promotion has been suggested to be one of the most

cost-effective interventions for prevention of infectious diseases.” (Biran et al.

2014). In addition to having proper resources and facilities, hygiene practices

was heavily influenced by student's’ knowledge and attitudes towards hygiene.

“Children cite number of reasons for not washing hands which include laziness,

smell in the washing area/toilet, time it takes away from playing to

non-availability of soap or water.” (Biran at el.) Jee Hyun Rah et al in their study

of National Family Health Survey (2005-06) and National Family Health Survey

(2011) found that, “improved sanitation and hygiene practices results in

significantly reduce incidents of stunting among children of age group between

0 to 23 months. Also improved hand washing practices before food and after

defecation is inversely associated with child stunting and the association

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becomes stronger among household with access to toilet facility and piped

water.”

“Oral hygiene practices are inversely associated with school grade and

also females have more hygiene related knowledge as compared to males.”

Kuppuswamy et al (1999). According to the study conducted in Ethiopia, past

reviews about personal hygiene indicate that “perception strongly influences

one’s hand washing beliefs and practices.” Additionally, few investigators have

examined hygiene KABP specifically among rural school children, a population

especially susceptible to communicable diseases. Shrestha and Angolkar (2015)

found, “a statistically significant improvement in knowledge and practice of

hand washing before and after health education intervention by doing baseline

and endline survey of students in primary schools in South India.”

The proposed targets for of WASH and indicators post-2015 are:

1. No one defecates in open by year 2025.

2. Everyone has safe water, sanitation and hygiene at home by year 2030 .

3. By 2030 everyone uses basic drinking-water supply and handwashing facilities when at

home, all schools and health centres provide all users with basic drinking-water supply

and adequate sanitation facilities, hand washing facilities and menstrual hygiene

facilities, and inequalities in access to each of these services have been progressively

eliminated.

4. All schools and health centers have water, sanitation and hygiene - by year 2030.

5. Water, sanitation and hygiene are sustainable and inequalities have been progressively

eliminated by year 2040.

“Implementation of reform processes in the field (of sanitation) has

often failed, because involvement and commitment of stakeholders at all levels

has been inadequate. It is essential to build the capacity of sector

professionals, civil society and communities to understand, commit to and

promote the new policies” - (Osmo T Seppala, 2002). Aneyusia et al (2007)

proposed that, “perspectives from the corporate social responsibility discourse

have the potential to provide both the ‘pull’ for seizing the business

opportunity for profit while serving social needs, and the ‘push’ to overcome

the barriers in order to serve a wider social purpose for corporation.”

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Study objective

The objectives of the study was to evaluate the KABP of hygiene and

handwashing, and to assess the extent to which proper knowledge on hygiene

practices is associated with personal hygiene characteristics among rural

school children in 6 states of India. Information from this study was meant to

serve as baseline data for future school-based hygiene intervention programs

in schools of rural India.

The study follows a step-wedge research design. The objective of the

study as mentioned above was to understand the knowledge practice aptitude

and behaviour among school children in states of India. The present baseline

data is from 1314 children across 90 schools of 6 states of India.

The study data was collected from students, teachers and school heads

- principals/vice principals. The data was collected in a semi-structured

questionnaire. The questions were asked around water, hygiene and sanitation

in households and schools.

Results from the study

A total of 1314 children across 6 states were interviewed. The

distribution of children is as follows :- 248 children from Andhra Pradesh, 215

from Bihar, 225 from Maharashtra, 220 from Rajasthan, 183 from Telangana

and 223 from Uttar Pradesh. The children were from age group 6-16 years

studying in grade 3 to grade 8. The mean age of children was 9.8 with standard

deviation of 1.3.

48% of the children interviewed were girls and remaining (around 52%)

were boys. In the areas of the study no significant difference in hygiene

practices was found among girls and the boys. Though there was differences

across states

Socio-Economic status: The survey was conducted in rural areas and

predominantly in government-run schools (except in Rajasthan where children

from private schools were also interviewed). In Rajasthan and Maharashtra

parents were found to be most educated compared to rest of the states under

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study. Absence of formal education among parents was found highest in

Telangana with 50% of both the parents not being educated. In Rajasthan, the

education levels of parents of children interviewed was better where 79%

fathers and 51% mothers have completed at least secondary school. But

interestingly it was found that education level has little to do with sending

children to private as opposed to public schools in Rajasthan. But this

difference of parents education institutes was found to be affecting the

practices and knowledge of children across these two states i.e. Rajasthan and

Maharashtra.

Most of the children reported having television (84%) at home and 50%

reported having mobile phones. 88% children have never used internet. The

use of internet was 31% in Rajasthan and less than 1% in Telengana and

around 2% in Andhra Pradesh. At the same time presence of television was

found to be having no effect on handwashing practices across all the states.

Drinking water : The source of drinking water varies across states in India.

Primary source of drinking water at home was reported to be a tubewell or

borewell in Rajasthan. The source of drinking water at schools remains same

as at home in the states. In Maharashtra, it was reported to be public tap and

in rest all the states primary source was handpump. For only 42% of

households water facility was available in their own yard. Children consider

water to be drinkable when it either tastes well or looks clean.

Perception of drinking water also varies across the states. Where 87%

of children in Maharashtra consider that water should be definitely

treated before drinking and 43% reported that water was boiled in their

house before drinking, But only 28% children in Telangana think that it was

imperative to treat water before drinking. In fact 20% children in Telangana

think that water treatment was not not at all required and do not think so

before drinking.

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Exhibit 2:Primary source of drinking water at home (n=1314)

Access to Water Supply and Use of Household Water Treatment Technologies and Safe Storage

Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Percentage of households that use an improved drinking water source

49.65% 48.37% 57.33% 77.98% 76.5% 49.78%

Percentage of households where drinking water is less than 500m from house

93.15% 94.42% 95.56% 84.86% 99.00% 93.72%

Percentage of respondents who agree that their drinking water needs to be treated at home

62.90% 6.98% 5.78 % 24.88% 47.50% 20.18%

Percentage of children who think it is absolutely necessary to treat water before drinking

63% 68% 87% 25% 28% 59%

Percentage of children who think no water treatment is required before drinking

29% 9% 4% 37% 20% 9%

Table 1: Water availability and children’s perception and practice of

clean water (n=1314)

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Sanitation: Only 39% children reported presence of toilet at home. The

lowest number of toilets were reported in Telangana (16%), whereas 57%

children reported toilets in Maharashtra followed by 43% in Rajasthan.

However, around 50% usage rate was pointed out by the respondents.

Hence, open defecation mainly in the field or vacant land (47%) was

widespread. There was no gender wise difference found in the open

defecation practice. But interestingly it was found that, young children of

age 6-7 years reported higher use of toilets at home. For older children

the use of toilets decreases. This needs further probing with the younger

children as number of younger children was low (17) in the survey.

Children reported high level of personal hygiene measured by bathing

and oral hygiene. 93% children reported that they bathe everyday with soap.

All the states except Telangana close to all the the children reported brushing

their teeth everyday. Only 20% children reported brushing their teeth every

day in Telangana. This again needs further exploration.

Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Percentage of households with access to an improved sanitation facility

88.46% 87.95% 96.88% 96.00% 93.33% 92.65%

Percentage of households where the toilet is in the house or in the yard 85.90% 86.75% 95.31% 46.40% 73.33% 86.76% Percentage of households using the available (improved) sanitation facility

2.56% 24.10% 45.78% 94.53% 76.66% 34.94%

Table 2: Access and use of sanitary facilities for disposal of human

excreta (n=1314)

Cleaning Teeth and Taking Bath

Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Percentage of children reported daily cleaning of teeth

97.98 99.07 94 94 20.11 98.21

Percentage of children reported bathing daily with soap

94.35 94.88 94 94 92.35 88.79

Table 3: Children’s personal hygiene (n=1314)

In all the schools, children reported presence of flush toilets. But

construction of separate toilets for girls still needs to reach 100%.

Presence of toilets for disabled was also extremely poor across all the

states. Both girls and boys think that number of toilets in the school was

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sufficient to use. Teachers on the other hand, emphasised the need of

increasing number of toilets in the school to improve the useage. As

teachers pointed out urination in open field by the children, particularly boys.

They also pointed at the need of maintenance and cleanliness of the school

toilets as teachers complaint of foul smell in the school toilets.

SEPARATE TOILET for Girls and Disabled

Andhra Pradesh

Bihar Maharashtra

Rajasthan Uttar Pradesh

Telengana

Separate toilet for girls

77% 93% 96% 74% 86% 83%

Separate toilet for disabled

1% 15% 12% 10% <1% 5%

Table 4: Separate toilet for girls and disabled in school (n=1314)

Handwashing practices - As discussed above hand washing has a direct

relation with the health of children. The practice of hand washing has to be

inculcated among children from early age on. The peer effect of handwashing

and hygiene was maximum in terms of personal hygiene practices. There was

no difference found in the practice among boys and girls but it was noted that

with age the practice of handwashing improved at certain instances. 0.5

point correlation was found between knowledge and practice of hand washing.

If proper mediums was provided right knowledge can turn into required

practices. Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Percentage of households with soap and water at a hand-washing station commonly used by family members

41.66% 57.30% 84.69% 61.00% 70.50% 40.56%

Percentage of respondents who know all critical moments for hand washing

24.71% 33.49% 33.52% 44.69% 39.00% 34.34%

Percentage of households with soap or locally available cleansing agent for hand washing anywhere in the household

48.43% 83.26% 84.89% 69.00% 72.67% 86.55%

Table 4: Hand washing with soap at critical moments(n=1314)

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Knowledge and practice of hand washing: There is increasing need to

improve knowledge about hand washing. Thought most of the children

understand the importance of washing hands before handling food. But few

children understand the need of washing hands before cooking except in

Telangana. It is found that in the rural households in India, the elder siblings

were responsible for taking care of the younger ones. It includes feeding,

washing and changing clothes. It is extremely important to teach them to

follow the practice of washing hands with soap and water before taking care of

younger ones at home. Both knowledge and practice about the same needs

attention.

As can be seen, there is a general gap between knowledge and practice

of hygiene. The difference in these proportions is statistically significant as can

be seen from the table below, except for defecation and urination where

knowledge matches closely with practice.

BELIEF RELATED TO HAND WASHING (%)

Activity Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Hand washing before an activity

Cooking 4 25 49 6 77 6

Handling food 88 78 75 85 68 85

Feeding someone/infant 27 35 36 30 48 30

Hand washing after an activity

Defecation and Urination 52 60 61 69 71 69

Eating 37 46 33 42 45 42

Sweeping 7 12 24 5 26 5

Touching pets or handling animals and waste

40 28 19 43 39 43

Cleaning child’s urine/stool 5 7 12 10 18 10

After playing 3 24 11 35 0 35

Table 5: Knowledge of hand washing practices (n=1314)

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ACTION OF HAND WASHING (%)

Activity Andhra Pradesh

Bihar Maharashtra

Rajasthan

Telangana

Uttar Pradesh

Hand washing before an activity

Cooking 3 24 43 5 19 5

Handling food 31 48 23 52 26 52

Feeding someone/infant 11 9 14 13 22 13

Hand washing after an activity

Defecation and Urination 52 51 56 62 66 62

Eating 48 30 30 31 48 31

Sweeping 4 12 14 6 16 6

Touching pets or handling animals and waste

27 22 13 35 39 35

Cleaning child’s urine/stool 1 17 16 5 28 5

After playing 0 20 9 31 0 31

Table 6: Practice of handwashing among children (n=1314)

Hypothesis Test: Difference between Proportions (n=1314)1

Is the proportion of children reporting that they have knowledgeabout handwashing significantly different from their practise of

handwashing ?

Variable  pknowledge ppractice z­score  p­value Statisticall

y Significant? 

Handwashing before an activity

Cooking.297

(yes=390).205

(yes=269)5.4454 0

Yes(p<0.05)

Feedingsomeone

.38(yes=499)

.159(yes=209)

12.751 0Yes

(p<0.05)

1 Two proportion z-test, calculated at 5% level of significance. Chi-square test of independence would give the same result.

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Handwashing after an activity 

Defecation and 

Urination  

.634 (ys=1604) 

.61(yes=801) 

1.5134  .13104 No 

(p>0.05 

Sweeping  .285 

(yes=374) .132 

(yes=174) 9.6033  0 

Yes (p<0.05) 

Cleaning child’s 

urine/stool 

 .096 

(yes=126) 

.148 (yes=195) 

­4.1104  0 Yes 

(p<0.05) 

Table 7: Hypothesis testing ­ children reporting hand washing being 

different from their practice of hand washing 

 

CORRELATION MATRIX (n=1314)

In general do

you wash hands with soap

Toilet at home

Television

Mother's education

Father's education

Practice of hand

washing Diarrhea in last 14 days 0.01 -0.03 0.07 0.04 0.06 -0.01

Absenteeism from school in one month

0.00 0.00 0.01 -0.01 0.02 -0.04

Practice of hand washing -0.15 - 0.03 0.09 -0.01 -

Knowledge of hand washing - - -0.04 -0.01 0.00 0.56

Table 8: correlation between different variables 

Andhra

Pradesh Bihar Mahara

shtra Rajastha

n Telangana Uttar

Pradesh Percentage of primary and secondary schools with an improved source (in rural areas) of water * on premises and water points accessible to all users during school hours.

63.64% 23.33% 25.00% 53.84% 50.00% 46.67%

*piped water into school, yard or plot or a standpipe/public tap or a tube well /borehole

Table 7: Hygiene facilities indicator(n=1314)

Implications and conclusion: The KABP baseline data opens many windows

and enables a deeper understanding of the state of affairs at the grass root

level. There are some of the important implications from this analysis of the

data on design of the curriculum. Activity based and project based learning

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methods need to be introduced in the school curriculum. While

integrating in textbooks will not work, teachers need to introduce these

ideas as activities in their lesson plans and delivery. At the same time

project based learning models are required to ensure learning for larger

communities around the issue to have larger impact on families and

communities.

Treatment of water before drinking needs immediate attention and this

can be introduced through the environmental studies curriculum itself which

already includes such topics.

Besides teaching only students it is important to educate parents and

community at large to inculcate the habit of right hygienic prices. Knowledge

about hygiene was found to be getting translated to practice. There was little

relation between availability of media like television in the households to

awareness levels of children about hygiene practices. It was recommended

that TV commercials and other media commercials are designed in a way so as

they create higher awareness levels around hygiene practices in families. Social

messaging is more important and impactful than direct selling.

There is an urgent need for improvement in sanitation infrastructure in

schools. Where facilities exist, cleanliness and hygiene is a challenge.

Awareness levels through posters and graphics in toilet areas can help

sensitize children and reinforce what is discussed by teachers in the

classrooms. At the same time gender separated toilet facilities need to be

created especially in public schools. Separate toilets for disabled are required

to be created

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References Aneysuria K; Cynthia M; White Stuart (2007). Can corporate social responsibility resolve the sanitation question in developing Asian countries?. Ecological Economics, Volume 62, Issue1, 1 April 2007, pp 174–183 http://www.sciencedirect.com/science/article/pii/S0921800906003004 Osmo T Seppälä (2002). Effective water and sanitation policy reform implementation: need for systemic approach and stakeholder participation. Water Policy Volume 4, Issue 4, 2002, pp 367–388 http://www.sciencedirect.com/science/article/pii/S1366701702000363 Curtis VA, Danquah LO, Aunger RV (2009). Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res. 2009;4:655–673. Facts and Figures on hand washing by UNICEF, http://unicef.in/Story/129/Fast-Facts-And-Figures-About-Handwashing Birna Adam, Schmidt Wolf-Peter, Varadharajan Kiruba Sankar et. al. (2014) Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Volume 2, No. 3, e145–e154, March 2014 UNICEF (2012), State of Palestine, School water, sanitation and hygiene knowledge attitude and practice survey Dutton Pennelope, Peschiera Rocio Florez, Nguyen Nga Kem (2011) The power of primary schools to change and sustain handwashing with soap among children: The care of Vietnam and Peru. The World Bank’s water and sanitation program. SQUAT research brief no. 1 (2014), Sanitation , quality, use, access & trends. UNICEF (2015), Post-2015 wash targets and indicators. outcomes of an expert consultation. USAID - HIP (2010) Access and behavioral outcome indicators for water, sanitation and hygiene