Motivating school communities towards behavior change and local ownership: a gamification intervention to prevent trachoma at primary schools in southern Ethiopia

Abstract

Background

Ethiopia alone carries 49% of the global burden of trachoma, associated with a lack of safe water, sanitation and hygiene (WASH) and poor health practices. The aim of this study was to examine whether gamification among schoolchildren and promotion of local ownership of school WASH is associated with healthy behaviors and WASH infrastructure improvements.

Methods

Application of the Accelerate gamification intervention for elimination of trachoma, with an emphasis on gamification among schoolchildren and community involvement in motivating face-washing, handwashing and functional use of latrines, was undertaken.

Results

The study was conducted over 9 mo in 223 rural schools from six districts within the intervention area, reaching 93 518 schoolchildren. At baseline, students were observed washing their hands after using latrines in 23 (10.3%) schools. This increased to 132 (59%) schools (p≤0.001) at follow-up. The number of latrines increased from 585 at baseline to 594 at follow-up (p=0.031). The availability of handwashing stations in schools increased from 31 (13.9%) with water access (8%) and soap (5%) to 155 (69.5%) schools with handwashing stations with water access in 153 (98.7%) (p<0.001) and soap in 121 (78%) (p<0.001).

Conclusions

Motivational strategies such as gamification among schoolchildren and promotion of local ownership of school WASH may be associated with healthy behaviors and WASH infrastructure improvements.

Introduction

The leading infectious cause of blindness globally is attributed to trachoma, a disease caused by Chlamydia trachomatis. Spread through contact with nasal and ocular discharge from an infected person via eye-seeking flies, touch and sharing of clothes,¹ trachoma is most prevalent in rural communities, where infrastructure for adequate sanitation and clean water is limited. Repeated infections lead to severe scarring of the inner eyelid due to inverted eyelashes scratching the cornea, causing pain, irreversible damage to the eye and blindness.² Trachoma places a socioeconomic burden on both individuals and communities. The largest affected populations of trachoma are children, due to their poor hygiene and tendency to touch their faces, and women, as a result of being caretakers exposed to infected children.³ Prevention can be achieved through behavioral change⁴ and access to clean water, sanitation facilities and healthy hygiene.⁵

Ethiopia, accounting for 49% of the global trachoma burden, has 64.6 million people at risk of the disease.^6,7 UNICEF reported that only 20% of schools in Ethiopia have basic hygiene services or basic drinking water, preventing students from practicing proper hygiene.⁸ The prevalence of active trachoma among children in Ethiopia is 26.9%. Children who had no access to latrines and those who did not use soap were 6 and 3.3 times more likely to contract trachoma, respectively.⁹ Ethiopia has prioritized trachoma elimination in tandem with the WHO by signing the VISION 2020 Initiative in 2002, creating a 20-y plan to eliminate the disease.⁹

The Surgery, Antibiotics, Facial Cleanliness, and Environment Improvements (SAFE) strategy is the recommended WHO program to eliminate trachoma. The first two components of the SAFE strategy, surgery and antibiotics, focus on treatment. The other two components, facial cleanliness and environmental improvements (F&E), focus on prevention¹⁰ and sustaining gains made through treatment. Most trachoma programs in Ethiopia focus on surgery and antibiotics. The F&E components of the strategy are usually underemphasized due to the high cost involved in constructing water, sanitation and hygiene (WASH) facilities, and the time that it takes to change norms and sustain behavior changes such as face-washing and hand hygiene.¹¹ Regardless, F&E measures are critical to trachoma prevention and should be expanded in order to reach elimination.¹²

The Accelerate program was implemented in 14 countries, including Ethiopia. The consulting company ThinkPlace, following an initial assessment, used a targeted design assessment to develop a set of four F&E interventions, endorsed by the Ministry of Health (MoH), to be implemented in four regions of Ethiopia, namely, Afar, Somali, Southern Nations, Nationalities and Peoples Region (SNNPR) and South West Ethiopia Peoples’ Region (SWEPR). These interventions aimed to strengthen the capacity of the MoH and Ministry of Education and their subsequent structures to promote F&E behavior change in support of neglected tropical disease elimination and control programs. One of these interventions is gamification, for promoting proper hygiene practices among young children in schools, with an emphasis on face-washing, handwashing and functional latrine use. Gamification is the application of game mechanics into non-game environments in order to motivate individuals and deepen their engagement and learning.¹³ The gamification intervention was implemented in SNNPR and SWEPR by neglected tropical diseases, advocacy, learning, action (NALA), a public health non-governmental organization, in collaboration with the regional health and education bureaus and Sightsavers, an international non-profit organization working to prevent avoidable blindness. The objective of this study was to examine whether gamification among schoolchildren and promotion of local ownership of school WASH is associated with healthy behaviors and WASH infrastructure improvements.

Materials and Methods

The school-based gamification intervention was implemented in 30 districts in SNNPR and SWEPR Ethiopia, all endemic for trachoma, with a prevalence of >20% from February 2021 to 2023. WASH advocacy for locally improved infrastructure was part of the implementation, but direct funding for WASH infrastructure was not included in the program. None of the surveyed districts had received any intervention by NALA prior to Accelerate.

The study reported here was conducted in schools from three randomly selected zones (Basketo Special Woreda, Kafa and Silti) in southern Ethiopia from September 2021 to July 2022. The school program focused on the following key behaviors: handwashing, face-washing, using the latrine, keeping a clean environment and sharing health messages. Although not always a target of F&E programs, hand hygiene was included as a key prevention behavior as hands may transfer bacteria to the eyes during face wiping and touching.⁴

An integral part of the school health program was a focus on improving teacher effectiveness by embedding teaching skills into the training materials and reinforcing their professional capacity to deliver more learner-centered approaches in the classroom,¹⁴ such as through educational games. The intervention curriculum developed for Accelerate included three games aimed at promoting trachoma prevention, differentiated by age level: (1) a storybook with activities for early childhood (grades 1–2); (2) a board game centered on prevention behaviors for upper primary students (grades 3–5); and (3) a competitive challenge game directed at students active in school health and WASH clubs, with challenges to improve their school environment and teach others. The intervention curriculum was informed by the ‘Attention, Relevance, Confidence, and Satisfaction’ (ARCS) model¹⁵ for motivational design, which seeks to enhance learner attention–level of student engagement, relevance–belief by students that the content relates to benefits in their own lives, confidence–perceived ability of students to succeed (activities are age- and skill-appropriate) and satisfaction–motivation of students to use new knowledge and skills learned from the games. The ARCS strategy is also relevant to integrating other diverse activities into health lessons, such as music, art and collaborative group work, thus reaching students who may learn better through non-lecture–based methods.¹⁶ Early childhood strategies such as play and storytelling were also emphasized in the training.¹⁷ The gamification methodology also allowed teachers to modify the games and more smoothly incorporate them into their own lessons, making the intervention more sustainable in the long run.

To promote local ownership of the implementation, a comprehensive delivery mechanism was developed for Accelerate that included direct training by NALA of two district education officers and an Accelerate Champion (AC). Champions were selected from the education office in each district to act as the focal point for the gamification intervention, ensuring successful cascading of the training, implementation of the intervention and monitoring of activities. These government officers were chosen for their ability to assume ownership of these activities and integrate them into existing structures, as well as for their commitment to the program and motivation to continue advocating for health and WASH improvements in the schools after the project's end. The training was then cascaded to the Parent-Teacher Association (PTA) and to school representatives (Figure 1). Within schools, students attending the health and WASH clubs were motivated to maintain their own hygiene and monitor the school WASH conditions.

Figure 1.

Cascading of the gamification intervention to the school community. Full arrow: training. Dotted arrow: consultation.

School level data were collected by ACs, from six randomly selected districts at baseline and 9 mo into the implementation. Data collected included assessments of hygiene-related behaviors and observations of students' behavior, as well as an assessment of sanitation and hygiene infrastructure.

Statistical analysis

Descriptive analysis was used to describe characteristics of the participating districts. Paired t-tests were used to compare variables measured at baseline and at follow-up and the ANOVA test was used to compare variables between districts. A p-value of <0.05 was considered significant. SPSS version 28 (IBM Corp. IBM SPSS Statistics for Windows, Armonk, NY, USA) was used for analysis.

Results

This study included 223 schools from six districts, with 93 518 school children (boys=50 744, girls=42 774) considered the direct beneficiaries (Table 1). In most schools there was a PTA at both baseline and follow-up. Health clubs were present in 54% (n=121) of the schools at baseline and in 99% (n=221) at follow-up (p<0.001). WASH clubs were present in only 36 (15.5%) schools at baseline and increased to 108 (46.4%) schools at follow-up (p<0.001) (Table 1).

Table 1.

Characteristics of districts included in the study, in the Southern Nations, Nationalities and Peoples’ Region (SNNPR) and SouthWest Ethiopian Peoples’ Region (SWEPR), Ethiopia

Name of district	Alicho Wuriro	Basketo	Chena	Cheta	Decha	Misrak A/B	Total schools
Schools, no. at baseline/ follow-up	35/32	35/35	33/33	31/31	50/48	39/35	223/214
Latrines, no. at baseline/ follow-up	90/117	84/80	97/98	61/82	128/118	125/99	585/594 p=0.031
PTA, no. at baseline/ follow-up	35/32	35/35	33/33	31/27	50/48	39/36	p=0.41
Health club, no. at baseline/ follow-up	32/31	35/35	1/33	0/31	25/48	28/35	p<0.001
WASH club, no. at baseline/ follow-up	1/31	35/35	0/0	0/8	0/12	0/16	p<0.001

Abbreviations: PTA, Parent-Teacher Association; WASH, water, sanitation and hygiene.

Observations regarding students' hygiene-related behaviors on school grounds found that although students in 207 (92.8%) schools at baseline used latrines, handwashing after latrine use was observed only in 23 (10.3%) schools. During follow-up, handwashing after using latrines increased to a total of 132 (59%) schools (p<0.001).

The number of latrines at schools in this study increased from 585 latrines at baseline to 594 latrines following the implementation (p=0.031) (Table 1). The number of latrines for girls increased from 193 at baseline to 209 at follow-up (p<0.001). Safe and accessible latrines, defined as having a clear path with safe access for use,¹⁸ were reported in 50% (n=112) of the schools at baseline and increased to 83% (n=185) of the schools at follow-up (p<0.001).

Conditions of latrines¹⁹ also improved following the implementation. At baseline, 147 (65.7%) schools reported latrines being either ‘somewhat dirty’ or ‘very dirty’. At follow-up, this number decreased to 66 (27.6%) schools. Latrines reported as ‘somewhat clean’ or ‘very clean’ increased from 76 (30%) schools at baseline to 157 (63.5%) schools at follow-up (p<0.001). The presence of flies was also tracked due to their nature of being vectors for trachoma transmission.¹⁹ At baseline, 123 (53%) schools reported having ‘few flies’ and 87 (37%) reported having ‘many flies’. Only 13 schools reported at baseline having ‘no flies’ in latrines. At follow-up, most schools (169 [72.5%]) reported having ‘few flies’ and 28 (12.5%) schools reported having ‘many flies’. Schools reporting ‘no flies’ increased at follow-up to 28 (12.5%) schools (p<0.001). In terms of cleaning the latrines, at baseline most of the schools (n=175, 78%) reported they cleaned latrines once a week, and in 35 (16%) schools twice a week. At follow-up, the number of schools that reported to clean once a week increased (n=183, 82%), as did the number of schools that cleaned latrines twice a week (n=40, 18%) (p=0.02).

At baseline, only 31 (13.3%) schools had handwashing stations, while 192 (82.4%) schools had no available handwashing stations. Moreover, in schools that had handwashing stations at baseline, only 20 had water available and 13 had soap available. This number increased following the implementation, with 155 (69.5%) schools observed to have handwashing stations available (p<0.001) (Figure 2). In many of these schools, water (n=153, 98.7%) (p<0.001) and soap (n=121, 78%) (p<0.001) were available. Also, the majority of these schools (n=133, 85.8%) had handwashing stations close (up to 10 m away) to the latrines. Schools that had a health club at baseline built more handwashing stations (114 vs 99, p<0.001).

Figure 2.

Changes in WASH infrastructure and health behavior of schoolchildren 9 mo from the beginning of implementation (n=223 schools).

Open defecation rates appeared to increase from baseline (9.4%) to follow-up (12.9%), while the presence of animals on school grounds decreased from baseline (11.2%) to follow-up (5.8%) (p=0.16).

Discussion

Following 9 mo of implementation, improvements in school WASH infrastructure were observed, alongside reported increases of schoolchildren practicing healthy behaviors, primarily handwashing after latrine use. Similarly, a significant increase in the number of school WASH and health clubs was reported following the intervention.

Construction of additional latrines and handwashing stations in most schools suggests the successful cascading of the project by the ACs, because NALA did not directly implement at school level. Therefore, it is possible that the engagement of the school community and school clubs led to these changes. A key part of the school-based implementation strategy was the inclusion of the PTA in the school level trainings, as well as the promotion of health and WASH clubs for students in the schools. The PTA is an important school-to-community linkage that ensures community participation in decision-making and provides material and financial support to the school²⁰ and is often responsible for fundraising for improvements within the schools, including WASH infrastructure. Schools that had a health club at baseline were more likely to construct a handwashing station. In a study of factors influencing WASH at rural schools in 14 low- and middle-income countries, two promoting factors included a PTA that supports WASH and the presence of a health club at the schools.²¹ Following this, a study in Bishoftu Town, Ethiopia, also showed a strong positive correlation between the presence of hygiene and WASH clubs and access to basic hygiene services. In 2023, Girmay et al. showed a strong correlation between community involvement in WASH at the school level and access to WASH.²² Community involvement was also a key factor in a study conducted in Northern Ethiopia, where the full SAFE strategy was implemented. Emerson and Rotondo found community women to be the ones to champion the construction of latrines in their homes and communities.²³ Because the gamification intervention did not include construction of WASH facilities, it is feasible that community members led these improvements in school WASH infrastructure following the intervention.

Although latrine use among children was observed in many schools at baseline, relatively few of them washed their hands afterwards. This discrepancy could be due to the distance of handwashing stations from latrines or due to a lack of knowledge regarding the importance of washing hands after latrine use.²⁴ Following the implementation, in most schools, handwashing after using the latrine increased. During the intervention, many schools constructed handwashing facilities close to the latrines, creating an enabling environment that may have encouraged more students to practice the health behaviors they had learned. In a study conducted in Zambia, Astle et al. suggested that the decrease in trachoma prevalence was attributed to the extensive trachoma program, which included both environmental and health education activities leading to altered hygiene practices, including latrines, face-washing, dish racks, rubbish pits and handwashing stations.²⁵ Therefore, creating an enabling environment such as increasing the number of handwashing facilities and placing them close to the latrines might promote improved hygiene and disease-prevention behaviors. Promotion of an enabling environment is also implied in the increase in the total number of latrines constructed specifically for girls, promoting an enabling environment for girls attending school. Gender-separate latrines benefit pubescent-age girls and promote their attendance in school, where they are exposed to the disease-prevention messages as well as a healthy learning environment.²⁶

Following the implementation, observations showed that the cleanliness of latrines improved, and the presence of flies reduced. In formative research conducted in Ethiopia by Greenland et al., where behaviors that are likely to contribute to trachoma transmission were mapped, it was found that one of the indicators which required targeting is latrine cleanliness. They found that when latrines were present in hyper-endemic areas, they were poorly constructed, maintained and used.⁴ Therefore, by encouraging school communities to increase the frequency of latrine cleaning, while providing safe and accessible latrines for schoolchildren, may promote increased use of latrines and lead to reduced transmission of trachoma. Despite these improvements, open defecation on school grounds was still observed. Open defecation is a normative practice in many rural communities in Ethiopia, particularly among young children. While it is unclear from the data why the open defecation rates increased, slippage from open defecation-free status is a known phenomenon, with estimated rates of slippage in Ethiopia at 15.9%. A systematic review by Abebe and Tucho looked at open defecation-free slippage at the community level, although some reasons for slippage may also be applicable to schools: discomfort using shared latrines, latrines that are dirty or unpleasant to use and insufficient motivation.²⁷ Therefore, behavior change interventions aimed at increasing latrine use should be targeted more thoroughly among schoolchildren with more attention paid towards making latrines attractive to use.¹⁹

Improvements in WASH infrastructure were not found equally across districts. In some districts WASH improvements increased significantly, whereas in others a decrease in available WASH facilities was found. Although the ACs were government officers who were selected for their ability to assume ownership of the activities and mainstream them into existing structures, it is possible that their personal characteristics differed and may have impacted how the implementation was delivered across districts. In a study conducted by George et al. in 2022, where the aim was to identify, analyze and group characteristics of champions who have successfully promoted the adoption of new initiatives within a healthcare delivery system, the authors found that the characteristics of a successful champion include being empathetic, curious, physically present, approachable and often soliciting feedback from others.²⁸ In 2012, Weiner et al. conducted a study among physician champions and described champions as being innovative people who step outside of their organizationally prescribed roles to advocate for innovations, serving as ambassadors for the program and advocating for additional resources.²⁹ Our results may imply that the variance in WASH improvements across districts is a result of differences in the personal characteristics of the champions.

Our study has some limitations. The relatively short follow-up period did not allow for studying the long-term impacts of the intervention. Furthermore, some schools were not included in the follow-up assessment and therefore the results presented in this study might be underestimated. The conditions of latrines were evaluated subjectively by the ACs and although all training for ACs was similar, observer bias might have occurred. Also, facial cleanliness was measured differently at baseline and endline, and thus could not be used as an indicator to determine the success of the intervention. Finally, the study did not include an assessment of community engagement and construction of WASH facilities. Yet, based on information reported by the ACs, no other known WASH-related interventions were conducted in these districts parallel to this intervention. The strengths of our study include a relatively large sample of schools from different districts in two regions in south Ethiopia.

Conclusions

The study lends support to the concept that creating a motivating environment, through local ownership and local leadership, is of great importance for sustained elimination of trachoma. Further research regarding the impact of behavior change by student-centered engagement strategies in schools, promoting local ownership of school WASH and means for integrating hygiene and sanitation messaging into the primary school curricula, is needed.

Authors’ contributions

NC and BCS are equal contributors. NC, DBT, MB, LGW and MMD designed the study protocol; AM, AS and NZK carried out the assessment; AS and RG conducted analysis and interpretation of these data. NC, BCS, SB and RG drafted the manuscript; DBT, SB, NZK, MB, LGW, MMD, RBW, GS and ZB critically revised the manuscript for intellectual content. All the authors read and approved the final manuscript. MB is the guarantor of the paper.

Acknowledgments

We would like to express our deep gratuity to all heads, vice heads, experts and Accelerate Champions in the Accelerate project from the Southern Nations, Nationalities and Peoples’ Region (SNNPR) and SouthWest Ethiopian Peoples’ Region (SWEPR), as well as to the zonal supportive supervision teams and the district monthly follow-up teams for their valuable contribution to the implementation of this study. We would like to thank ThinkPlace for providing guidance on the games that were implemented in this study.

Funding

The community intervention and the production of this manuscript was funded by a consortium of donors to Sightsavers' Accelerate programme, including Bill and Melinda Gates Foundation, Children's Investment Fund Foundation, The ELMA Foundation, Virgin Unite, and an Anonymous donor. The funders had no role in the writing of the manuscript or the decision to submit it for publication.

Competing interests

Not applicable.

Ethical approval

The Regional Health and Education bureaus provided approval for conducting the intervention and the data collection (Gra-NA-2114).

Data availability

The data underlying this research article is not publicly available, but can be provided by the corresponding author upon request.