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.

1. 1
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, RB
Vipin Yadav, CEO, Dure Technologies Pvt. Ltd.
Subash Ghosh, Public Health Expert, Dure Technologies Pvt. Ltd.

2. 2
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

3. 3
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,

4. 4
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.”

5. 5
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 a​ddition 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

6. 6
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.”

7. 7
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

8. 8
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.

9. 9
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 Maharash
tra
Rajasth
an
Telangan
a
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)

10. 10
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 Maharash
tra
Rajasth
an
Telanga
na
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 Mahar
ashtra
Rajast
han
Telanga
na
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

11. 11
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 Maharasht
ra
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 Mahara
shtra
Rajastha
n
Telanga
na
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)

12. 12
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 Maharas
htra
Rajastha
n
Telang
ana
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)

13. 13
ACTION OF HAND WASHING (%)
Activity
Andhra
Pradesh
Bihar Maharas
htra
Rajasth
an
Telanga
na
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 knowledge
about handwashing significantly different from their practise of
handwashing ?
Variable p​knowledge p​practice z­score p­value
Statisticall
y
Significant?
Handwashing before an activity
Cooking
.297
(yes=390)
.205
(yes=269)
5.4454 0
Yes
(p<0.05)
Feeding
someone
.38
(yes=499)
.159
(yes=209)
12.751 0
Yes
(p<0.05)
1
Two proportion z-test, calculated at 5% level of significance. Chi-square test of
independence would give the same result.

14. 14
Handwashing after an activity
Defecation
and
Urination
.634
(ys=1604)
.61(yes=80
1)
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/stoo
l
.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
Televisi
on
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

15. 15
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

16. 16
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