Cleaner, Happier, Healthier: Sesame Workshop's Water, Sanitation, and Hygiene Intervention among Low-Income Groups in Bangladesh and India

This paper evaluates a pilot intervention of Sesame Workshop's "Cleaner, Healthier, Happier" multi-media health communication approach promoting water, sanitation, and hygiene (WASH) knowledge, attitudes, and behaviours among vulnerable children and their families in impoverished areas of Sylhet, Bangladesh (n = 240) and Kolkata, India (n = 258). See Related Summaries below for details about the project, including the role of Raya, a new Muppet® that was developed and introduced to advocate for healthier WASH behaviours. The country teams created interventions that utilised two different approaches to WASH messaging: one that appealed to personal motivations for behaviours (the "me" intervention) and one that appealed to social motivations (the "we" intervention). The targeted WASH behaviours - using a latrine, washing one's hands, and wearing sandals - are all individual behaviours and would generally be conceptualised as such, yet the Principal Investigator and the Sesame Workshop research team also recognised that hygiene is a public health practice and that personal behaviours foster community health. The study examined both the overall impact of the interventions and the relative efficacy of these two approaches.

As the researchers explain, diarrhoea is among the top causes of young child mortality, and yet there are many challenges to the improving sanitation and hygiene that would prevent the disease. Culturally appropriate health behaviour change interventions are necessary to increase latrine use, a good hygiene practice that can significantly reduce rates of diarrhoea. In this work, there was continual communication with stakeholders in the community as well as with in-country researchers and local WASH experts to try to ensure that the intervention content and implementation were created with input from the communities it was designed to serve.

The entertainment-education initiative Sesame Street, based around a children's television programme, has had a presence in Bangladesh and India since about 2007, in the form of locally produced Sesame Street coproductions Sisimpur and Galli Galli Sim Sim. In addition to mass media, Sesame Workshop works with partners in many countries to implement community- and school-based programmes that use multiple channels and resources (audio-visual, print, digital) to engage children.

The teams from Sesame Workshop Bangladesh and Sesame Workshop India developed the "Cleaner, Healthier, Happier" content, co-created Raya, and adapted its implementation in high-need communities. Programme components included various forms of media and in-person activities. Raya was developed to be an appealing and relatable character for children in both Bangladesh and India. Raya is an energetic 6-year-old with long dark braided hair and wears a yellow embroidered kurta. She talks about latrines and defaecation in ways in which children from Bangladesh and India can supposedly identify. Community members, including children, were engaged during formative research as well as during the implementation phase of this intervention to address gaps in communication and aid in refining the education objectives.

Research instruments were designed by child development experts and were refined by in-country team members to ensure cultural and age appropriateness of materials. In-country researcher teams, along with non-governmental organisations (NGO) partners, chose community-based workers to take the messages of the project to the children and community members. These programme facilitators received multi-day training to implement the "Cleaner, Healthier, Happier" programme, and in-country researchers all had prior experience working with children and were trained in data collection methods.

The pilot intervention took place over a period of 3 months in 2014 (in Bangladesh) and 2014/2015 (in India). The programmes in both countries consisted of community-targeted mobile viewings where participants watched videos created for the project, followed by simple activities led by a facilitator such as small group games, stories to reinforce WASH messages, and activity sheets and child-targeted activities or workshops led by trained facilitators. Specifically, various media materials used included video (with WASH-relevant Muppet segments/inserts, live action films, and Sesame Workshop library content) and print resources (floor games, flip charts, books, and activity sheets). India had additional digital games developed for this project because the programme team had previous experience implementing such activities and saw them as an important, engaging, and motivating component of the project. Children were exposed to all content and activities in their community or through schools in Bangladesh, whereas adult caregivers were largely exposed only to the mobile community viewings, which were accessible to all members of the community.

As part of the "me" intervention, participants were told that engaging in good hygiene and sanitation behaviours would benefit the individual, making him or her healthier. The "we" intervention involved messaging that encouraged children to use improved behaviours to improve the health of their peer group and the community. These different approaches were overt in the programme's messaging. For example, individual motivation text may read "I wear sandals every time I go to the latrine; it keeps me healthy and clean", while the social motivation text reads "we wear sandals every time we go to the latrine; it keeps us healthy and clean". All of the print materials' text and images (in Bangladesh), the organisation of the activities (in India), the facilitator training, and the facilitation of the programme activities were either "me"- or "we"-focused.

In each country, a three-armed approach employed groups focused on the "me" and "we" interventions and a comparison group. Both the "me" and "we" groups improved in WASH measures over the comparison group; however, there were limited differences between the "me" and "we" groups. "If this research had found consistent and significant improvements in knowledge, attitudes, and behaviors attributable to one approach, it would suggest that the health communication endeavors use "me" or "we" in message delivery. Based on this work, regardless of approach, children benefited from exposure to the overall intervention." That is to say: Target behaviours, such as using the latrine, wearing shoes, and handwashing, improved when examining change before and after the intervention, and the intervention was predictive of positive knowledge, attitude, and behaviour change.

More specifically:

• Knowledge - See Table 4 in the paper, which presents the standardised knowledge change scores for questions such as: "Why should children wear slippers/sandals when they go to the toilet?". For adult knowledge in Bangladesh, the "me" and "we" group both had mean change scores greater than 1.0, indicating improvement in knowledge after the intervention compared to the mean change for comparison group participants (p < 0.001). In India, there was no significant difference between groups. Table 5 in the paper shows the linear regression model for the intervention predicting a change in knowledge. In both countries, change in child knowledge was not significantly predicted by the intervention.
• Attitudes - Looking at attitude scores in Table 4, it is evident that there was an increase for the parents in Bangladesh in the "me" and comparison groups on measures such as "It is important to use latrines.", and a decrease for the "we" group (p < 0.01). There is a significant increase in child attitudes for both intervention groups, compared to the comparison group (p < 0.05). In India, all groups showed slight increases in child attitudes, but with no significant differences. Again, see Table 5 for the regression model. In India, neither adult nor child attitudes was significantly predicted by the intervention.
• Behaviours:
  1. Latrines - Overall, as reported by parents, the percentage of children who defaecated in the open at home decreased from before to after the intervention (in Bangladesh 48.3 to 42.1%; in India 3.9 to 0.9%). Table 6 shows that participants from Bangladesh and India had positive change scores for the "me" and "we" groups with regard to use of an improved ventilated latrine at home (p < 0.001). Table 7 shows that participation in the intervention significantly predicted child latrine use at home. In Bangladesh but not India, the change in use of an improved latrine at school was also significantly predicted by the intervention (p < 0.001).
  2. Sandal and shoe wearing - As shown in Table 6, there were no significant differences in Bangladesh between the groups, but in India, the "we" group was significantly higher for children wearing their shoes "all the time" when going to defaecate (p < 0.001). The linear regression models indicate that change in wearing shoes outside the house was significantly predicted by the intervention in both countries (see Table 7).
  3. Handwashing - In India, the frequency of soap use when handwashing significantly increased for both intervention groups. The "we" group was slightly higher than the "me" group for all handwashing variables, but there were no significant differences between the intervention groups. In the linear regression models for Bangladesh, the intervention was a significant predictor for change in the frequency of children washing their hands immediately after defaecation and frequency of soap use by children after defaecation (see Table 7). The intervention was also shown to significantly predict frequency of child soap use in both countries.

The researchers note that the strength of this study is that this media intervention apparently reached the participants, as they observed high recall and understanding of the presented and novel materials. They observe that many participants were unable to discern the differences in intervention approaches ("me" versus "we" focus). Most children and all the adults across groups perceived the intervention as a social good, and not about improving individuals' health. Among the possible explanations: The distinction between social and individual orientations in South Asia may be less pronounced than it is in other countries.

There is concern that both adult and child participants provided responses that they perceived the researchers wanted or expected to hear. This "courtesy bias" has been shown to occur in other hygiene interventions. Future research could require the data collection team to make observations in the communities and participants' households around hygiene behaviours to gain a better understanding of response validity, and future instruments should include additional measures of social desirability to account for this, the researchers say.

Results of this work are limited due to lack of a randomised control trial but suggest that participants who received the "Cleaner, Healthier, Happier" interventions will be more informed and more likely to engage in healthier hygiene behaviours. This intervention lasted for 3 months and does not include research or information on long-term effects. It is possible that longer-term exposure would result in similar or even better outcomes.