Research on the Cost Effectiveness of Health and Hygiene Education through Play and Sports (HHETPS) via ReliefWeb

Accra, Ghana 🇬🇭

1. Background

The Government of Ghana (GoG)-UNICEF WASH programme has a significant focus on improving access to WASH in Schools. The Ghana Education Management Information System (EMIS) data for 2014/15 shows that 56 per cent of Ghanaian public basic schools have access to toilets and only 38 per cent have access to a water supply[1]. Whilst data is not available for hygiene in schools, the lack of water supply in 62 per cent of schools makes it unlikely in most schools that optimal hygiene practices are being followed. A growing body of research highlights the positive impacts that practicing good hygiene can have on the health of individuals and their communities, as well as its various social and economic benefits.

Hygiene is related to neglected conditions such as diarrheal and respiratory diseases – the two biggest killers of children[2]. An estimated 12,000 children die from diarrheal and pneumonia-related diseases each year in Ghana. Even though the provision of improved water supply and sanitation facilities make it easier to practice good hygiene, they are on their own insufficient to significantly decrease morbidity and mortality rates. Handwashing with soap at critical times, especially before eating and after contact with excreta, can reduce diarrheal disease by up to 47%[3], the prevalence of eye infections like trachoma by approximately 45%, and respiratory infections by about 20%[4] [5]. Good hygiene practices can also reduce the prevalence of respiratory infections, and skin infections, trachoma, parasites like roundworm and hookworm[6]. Lack of food hygiene has been suggested as a major contributor to diarrhoea in low-income settings’[7] [8]. Preventing children from coming into contact with animal faeces and keeping household surfaces clean, as well as fly control, will also lessen the risk of disease.

It is evident that raising awareness of the importance of hygiene is not enough on its own to change and sustain behaviour change. Demonstrating good hygiene practices as part of daily routines and sustaining this behaviour requires innovation. Approaches for promoting behaviour change include child-to child approach, life skills based hygiene education and hygiene education through play and sports.

UNICEF Ghana in collaboration with Right to Play is assisting the School Health Education Programme (SHEP) of the Ghana Education Service (GES) to utilise play-based health and hygiene education approaches in school health programming. Health and Hygiene Education through Play and Sports (HHETPS) is an innovative play based approach that uses play and sports as tools to help children develop knowledge, skills and attitudes needed to make healthy choices in everyday life. Using a sport and play based approach, Right to Play’s delivery model supports the development and mentorship of children and youth as agents of change who facilitate replicable and adaptable activities in and outside the school. The focus of the partnership is to promote behaviour change among participating children and youth.

UNICEF Ghana, GES-SHEP and Right to Play plan to roll out the implementation of the approach in 1,000 schools, with implementation in some schools on-going. An international consultancy is sought to complete operational research that will accompany the implementation of HHETPS to explore its cost effectiveness against more traditional approaches, and the practicalities of mainstreaming this approach into national curriculum.

2. Justification, Purpose and Utilisation of Results

Whilst several evaluations have been completed for the HHETPS approach[9] [10], there is little evidence of its effectiveness over more established approaches to school hygiene education approaches such as life-skills based training and school health clubs. The purpose of this research is to determine effectiveness of the approach against both established approaches and the basic measures that are currently included within the school curriculum.

The research will also explore in more detail what the basic measures are within the existing curriculum, as whilst it is generally identified that these exist within classes such as science, it is not objectively documented. This aspect of the research will also speak with key stakeholders to establish if in fact the national curriculum has sufficient scope to adopt a hygiene/health specific topic.

The research will also identify the costs associated with each approach. It is generally acknowledged that the costs of HHETPS are higher than those of established approaches and existing basic measures. However, if the effectiveness is found to be significantly higher the research will aim to reduce costs, via operational research, and seek to ensure effectiveness is retained.

UNICEF Ghana will utilise this research to make a programmatic decision whether or not to mainstream HHETPS within UNICEF-GoG programming, and minimise the cost implications of doing so. GoG-UNICEF is also currently working on a national costed strategy to deliver WASH in all basic schools in Ghana, this research will complement that work by providing an accurate estimate of the cost of delivering effective hygiene promotion. Following research into the curriculum and cost implications, the work will also identify if advocacy for incorporation of HHETPS (or alternative hygiene promotion methods) into the national curriculum is a strategic priority.

The primary audience and users of this research will be UNICEF Ghana, GES/SHEP, Right to Play and other WASH in Schools programme implementers. The secondary audience and users will be other partner organisations in Ghana and interested international institutions to whom this evidence will be useful in designing WASH behaviour change interventions.

3. Research Scope and Focus; Existing Information Sources

The research shall take place over a period of two years. With the first year focusing primarily on the effectiveness of the three types of approaches outlined above and investigating costs associated with each approach. The first year will also involve more detailed investigation into the existing school curriculum for hygiene promotion. The second year will focus on how to reduce the costs associated with HHETPS whilst retaining the effectiveness.

The research will focus on a mixture of urban and rural schools in both northern and southern Ghana, this is estimated to result in 12 research schools (further details below). Schools will be selected based on similar pupil sizes and all shall have pre-existing water and sanitation facilities with a similar level of coverage. The focus will be on knowledge, attitudes and practices, with the latter measured via proxy indicators and direct observation.

UNICEF Ghana is also completing research on the learning through play approach called Handwashing with Ananse. This has a more complex methodology in measuring school children’s handwashing behaviour, and research findings can help in triangulation of behaviour practices.

Key research questions to be answered will be (these will be further refined during project inception period):

· Approaches to Health/Hygiene Education in School Curriculum

o What are the current methods of hygiene/health education included within the school curriculum and teacher training?

o What are the gaps in the existing teaching training and school curriculum when compared to the topics covered in HHETPS and other established approaches to WASH in Schools Hygiene promotion?

o What gaps have been identified in the school and teacher hygiene and health education manuals when compared to the topics covered in HHETPS and other established approaches to WASH in Schools Hygiene promotion?

o Is it feasible to expand the school curriculum to include a HHETPS (or similar) approach to hygiene promotion? What cost implications would this have (in terms of material inputs and teacher training requirements)?

· Effectiveness of Approaches

o What are the levels of knowledge, attitudes and practices of school children related to hygiene when exposed to the three different types of hygiene intervention (HHETPS, established methods such as school health clubs and life-skills training, and existing school curriculum topics)?[11]

o For each approach, how often are school latrines found to be clean and handwashing stations found to have water and soap/ash available?

o For each approach how do attitudes of teachers and school management committees to hygiene behaviours and maintenance of facilities vary?

· Cost of Approaches/Cost Effectiveness

o What are the costs of each of the three approaches when applied for one year in a school?

o How much can the cost of HHETPS be reduced with effectiveness retained (UNICEF Ghana has agreement with implementing partners to trial a new low cost approach within current implementation modalities)?

o What is the cost-effectiveness of the approach?

o What are the methods of reducing the costs of implementing HHETPS?

Some existing evaluations and reports have been produced on HHETPS (previously mentioned), whilst the research should also identify best practice from other countries and global studies into this areas.

4. Research Process and Methodology, Specific Tasks

Year one of the research will focus on effectiveness/cost of approaches, methods of reducing the HHETPS cost and favourability of mainstreaming the HHETPS approach into the teacher training and school curriculum. The second year will focus on how to reduce the costs associated with HHETPS whilst retaining the effectiveness.

The appointed research consultancy will work with a UNICEF Ghana implementing partner (Right to Play) to identify the ways in which HHETPS can be made more cost-effective. At the end of the first year of research (August 2017) proposed changes to the methodology that will reduce the cost will be mutually agreed between UNICEF, Right to Play, SHEP and the research consultancy. Following which the revised methodology will be implemented by Right to Play (during the second year of the research) whilst the research consultancy leads on the evaluation of the effectiveness of the lower cost approach.

The research will employ both quantitative and qualitative methods to answer the research question outline above. The work shall commence with a desk review of relevant literature on school hygiene promotion in Ghana, with key global documents also included.

The consultancy will design and collect baseline data in all the 12 schools (one for each approach and covering urban/rural schools in north/south locations) following the methodologies outlined below. Schools will be selected to have similar enrolment rates, pre-existing WASH infrastructure, and prior exposure to the hygiene promotion methods being implemented. Consortium approaches are encouraged, with a lead international consultancy leading on research design, quality assurance and report writing. Whilst national consultants are also available within the team for supervision of data collection, local contextual understanding and representation of the research team in meetings as appropriate.

The implementation of HHETPS in schools will commence during the 2016/2017 academic year (which begins in September 2016). The consultant will use various assessments including surveys, key informant interviews, focus group discussions with school children, teachers and community members. The consultant will triangulate findings via direct observations and proxy indicators.

Desk Study

The work should commence with a desk study of relevant documents to HHETPS and hygiene promotion in schools in both Ghana and globally. Particularly with a focus on effectiveness of different approaches in addressing hygiene behaviour change in schools. Furthermore, a desk study will be completed of globally relevant literature.

Quantitative Survey

There will be periodic quantitative surveys completed in schools each term during the first year of research in order to determine the effectiveness of the approaches being followed. There will be similar approaches in year two when the HHETPS approach is implemented again using the lower cost implementation methods.

Focus Group Discussions (FGDs)

FGDs shall be conducted with school pupils (boys and girls), teachers and school management committees to get a more in-depth view on collective attitudes and practices. With teachers and school management committees this should extend to the management and maintenance of facilities.

FGDs will also be completed with teachers on the current approaches within the national curriculum for promoting improved hygiene behaviours.

Key Informant Interviews

Key Informant interviews should be held with a range of local and national level stakeholders in determination of the extensiveness of current hygiene promotion methods in the curriculum. This will include GES, SHEP, UNICEF and the Environment Health and Sanitation Directorate. These interviews will also cover perceptions on the feasibility of expanding the curriculum with new approaches.

Direct Observation

Direct observations of school children’s behaviour to handwashing and latrines usage, cleanliness of WASH infrastructure, functionality of WASH infrastructure and availability of water and soap/ash at handwashing stations will be used to triangulate findings.

Stakeholder Committee

GES/UNICEF/Right to Play shall constitute a stakeholder committee comprising GES (SHEP, Curriculum Research and Development Division (CRDD), Teacher Education Division and Basic Education Division), relevant academic institutions, UNICEF staff, sector stakeholders, principals of teacher training colleges to review the current teacher education and school curriculum to identify gaps in relation to Health and Hygiene Education. This committee will also receive bi-annual updates from the research institution.

Specific Tasks

Phase 1: Inception

1.1 Review relevant literature on hygiene promotion behaviour change approaches in schools (with literature review included as a section within the inception report) .

1.2 Consult with UNICEF/GoG/Right to Playon the proposed detailed approach and methodology to be used. This includes detailing the way in which ethical approval for working with children will be obtained (guidance can be offered by UNICEF).

1.3 Develop inception report that includes:

a) Proposal for analytical approach and methodology

b) Detailed sampling frame based on the considerations above, and proposed research locations.

c) All data collection instruments to be used for this research.

d) Quality assurance measures to be taken by the research team during data collection, data entry, data cleaning, and data analysis.

e) Detailed description of the suggested types of data analysis to be used during the analysis phase, and a data analysis protocol.

f) A detailed work plan and timeline

g) Clearly describe any possible limitations or discrepancies between the proposed approach and methodology and the requirements laid out in this TOR.

h) A proposed outline of the final analytical report.

1.4 Present the finalized agreed approach, methodology and work plan to the stakeholder committee, to be set up and organized by UNICEF.

1.5 Train team in all necessary data collection instruments and protocols, and any other equipment or methods to be deployed. The training is to be designed by the consultancy, must take place face-to-face in Ghana and is expected to last 3 to 5 working days. UNICEF Ghana and Right to Play will assist in logistical arrangements, and also with identification of suitable data collectors.

Phase 2: Data collection

2.1 Obtain required ethical approvals as agreed during the inception period

2.2 Supervise logistical preparations, field work and data collection according to the approach, methods, instruments and work plan as detailed in the final inception report (this will be assisted by Right to Play as a UNICEF implementing partner as far as practicable).

2.3 Provide bi-weekly email updates to UNICEF on the progress of the research, including the number and type of interviews and FGDs completed, and any important emerging issues (only during data collection).

2.4 This will be repeated each term as further data collection is carried out

Phase 3: Analysis and Review

3.1 Analyse all data according to the methods and protocols agreed during the inception phase.

3.2 Provide a short (5 pages) preliminary data analysis report after each main round of data collection (at the end of each term), providing a summary of key indicators and observations and comparison versus the three approaches

3.3 Prepare a draft final report summarizing the research approach, methodology and process (see section 4), and present a detailed analysis of findings with specific reference to the research questions as listed in section 4 of this TOR.

3.4 Prepare a PowerPoint presentation summarizing the contents of the draft final report, with a duration of no more than 30 minutes.

3.5 Present the draft findings to the Ghana stakeholder committee, via Skype or in person as appropriate.

3.6 Revise the draft final report and presentation based on the feedback received from UNICEF/GoG/Right to Play and the stakeholder group.

Phase 4: Reporting and Dissemination

4.1 Prepare a final report that includes an executive summary of no more than 4 pages, and an annex with a detailed bibliography, data collection instruments, and data tables (if not already included in the body of the report). The report must make explicit reference and provide responses to all research questions outlined in section 4 above. The report length should not exceed 30 pages (excluding appendices).

4.2 Prepare a shorter version of the final report, in co-authorship with the supervising UNICEF/GoG/Right to Play staff, suitable for publication in a relevant journal, and carry out the submission process.

4.3 Provide softcopies (MS Word, PowerPoint, and PDF) and three hard copies of the final report to UNICEF/GoG/Right to Play, ensuring a consistent formatting.

4.4 Provide UNICEF with the full dataset and statistical analysis syntax. Present the final report (no more than 30 minutes, unless otherwise agreed by UNICEF) at a dissemination event to be organized by UNICEF/GoG/Right to Play, via Skype or in person.

4.5 Finalise a 4 page technical brief outlining the methodology and key findings of the research (presented in an engaging format).

All written deliverables must be submitted in English, in Microsoft Word and PDF format, 11 point font, 1.5 line spacing, pages numbered, with a table of contents (automatic and with clickable links for navigation through the document), list of acronyms, list of tables and charts, and with a full bibliography of any external works cited and data sources used.

None of the products from this evaluation (including data and reports) may be used or disseminated for purposes other than this current evaluation assignment without the prior written consent of UNICEF Ghana.

5. Stakeholder Participation

UNICEF Ghana, GES/SHEP and Right to Play are the primary recipient of the results from this research and will use the knowledge generated to inform interventions. Secondary recipients will be others implementing WASH in Schools programmes.

UNICEF will convene a stakeholder committee comprising UNICEF staff, GES, (SHEP, principals of teacher training colleges, Right to Play and NGOs.

6. Accountabilities and Reporting

The institutional consultant reports to the WASH Specialist in UNICEF Ghana at the frequencies outlined above. UNICEF Ghana will review, provide feedback and ultimately approve or reject the deliverables submitted by the research team.

Upon signing the contract, the research team will designate a focal point who, together with the Principal Investigator, will be UNICEF’s main point of contact and will ensure that UNICEF’s guidance and feedback is promptly incorporated into the research design and process.

UNICEF Ghana will exercise supervisory responsibility for contractual purposes.

7. Expected Deliverables and Timelines

List of deliverables and timelines


Deliverable No.

Description of deliverables

Timing (estimated start date: September, 2016)

Month (tentative)



Draft inception report

3 weeks after signing the contract



Final inception report, incorporating feedback from UNICEF

1 week after receiving feedback



Presentation of inception report to stakeholder committee

Immediately after finalization of inception report, based on notice by UNICEF



Bi-weekly progress reports (whilst collecting data)

Every first Monday of the month



Preliminary data analysis (following each terms data collection)

4 weeks after conclusion of termly data collection



Draft final report & PowerPoint presentation

6 weeks after last terms data collection



Presentation of draft final report to reference group

Within 2 weeks of submitting the draft final report



Final report and presentation, incorporating all feedback from UNICEF and the reference group

Within 2 weeks of receiving feedback from UNICEF



4 page Technical Brief with key findings

Within 2 weeks of receiving feedback from UNICEF



Submission of final soft- and hard copies, full data set and statistical syntax

Within 2 weeks of receiving feedback from UNICEF



Submission of journal article summarizing the evaluation results

Within 4 weeks of submitting the final report

8. Dissemination Plan

The research team will assist UNICEF Ghana in disseminating the findings from this research as outlined above. UNICEF will ensure publication of results within internal mechanisms. The results will also be presented at a National Level Learning and Alliance Platform (NLLAP) event to disseminate within the WASH sector within Ghana. Via the stakeholder committee further dissemination will be encouraged.

9. Payment Schedule

Project payments will be made against the terms below.

· 20% upon submission of deliverable 1-3

· 60% upon completion, submission and approval of deliverables 4-5 (paid in 10% instalments after each term)

· 20% upon submission and approval of deliverables 6-11

10. Expected background and Experience

Proposals are expected to be from a research institution/consultancy with experience of working both internationally and within Ghana. Consortium approaches are encouraged, where an international consultancy provides research design and quality assurance, whilst Ghanaian consultancy/consultants (acting as team members) provide more regular in-country support and supervision of data collection.

Profile of Lead Institution

· The research institution must have demonstrated experience in developing theory-driven evaluation designs, methods, and instruments.

· Demonstrated experience in conducting complex field surveys on social science research questions using quantitative and qualitative instruments, preferably on similar research questions and using innovative, technology-enabled methods.

· Ability to work in complex partnerships with researchers, government and development partners, and strong capacity for managing a local research partner and providing close oversight.

Team Leader

· The Team Leader must have an advanced university degree in a relevant field (e.g. evaluation, social and behavioural sciences, economics, etc) and at least 5 years’ experience conducting research in the area of game-based interventions for learning and/or behaviour change, ideally in the field of water, sanitation and hygiene, including a strong track record of carefully and transparently analyzing complex qualitative and quantitative data sets.

Team Members

· Degrees relevant to the WASH sector

· Some team members must have experience within the WASH sector in Ghana

· Preferably strong WASH in Schools software implementation experience

· The research team must have excellent analytical and communication skills.

11. Submission Details

Structure of Technical Proposal

The technical proposal should be no more than 25 pages, 11 point font and 1.5 line spacing excluding Annexes. It should address the following areas:

· Experience of the institution in this area including past performance, especially as related to WASH in Schools programming;

· Principal Investigator experience and qualifications (include CV as Appendix);

· Description of other key personnel (include CVs as appendix);

· Summary of the proposed methodology;

· Detailed description of proposed data collection instruments, particularly on how costing data will be gathered and behaviours will be measured;

· Reflections on a possible sampling frame, including power calculations;

· Description of proposed field work oversight and operations plan;

· Quality control measures in data collection, data entry, cleaning and analysis;

· Description of the analytical software tools to be used;

· Protocol for transcription, translation and coding of qualitative data;

· Ethics review experience and proposal;

· Any other issues relevant to the TORs.

Structure of Financial Proposal

The financial proposal must be submitted in a separate sealed envelope from the Technical Proposal.

There is no length limit to the financial proposal. It should contain the following:

· A cost table covering all specific tasks and deliverables, containing unit costs and number of units;

· The budget narrative must explain the assumptions behind all cost estimates including any equipment to be purchased, number of travel days, number of field days (with due allowance for travel days).

· The financial proposal has to cover all cost elements to be incurred by the lead consultancy and should include costs of consortium members where applicable. No financial provisions will be made by UNICEF to the consultant outside of this contract.

Evaluation criteria of proposals is the following:

Technical – 70 percent

Technical Evaluation Criteria


1.1 Overall Response

-Completeness of response

-Overall concord between TOR requirements and proposal

10 5


1.2 Experience of Company and Key Personnel

  • Company profile indicating major work

  • Experience of co-personnel

  • Level of expertise with similar projects, including WASH in Schools experience

1.3 Proposed Methodology and Approach,


Total (maximum possible)


*Only proposals which receive a minimum of [55] points will be considered further

Financial – 30 points maximum

12. General Conditions: Procedures and Logistics

· The research team will work from their own offices, provide their own equipment (hardware and software) and organize all aspects of field logistics themselves.

· All costs related to this assignments have to be included in the financial proposal. No additional payments for staff time, travel or per diems will be provided outside the financial proposal.

· UNICEF will bear the costs for workshops and meetings with external partners (such as the reference group) as outlined in this TOR.

13. Policy both parties should be aware of:

· Under the consultancy agreements, a month is defined as 21 working days, and fees are prorated accordingly. Consultants are not paid for weekends or public holidays.

· Consultants are not entitled to payment of overtime. All remuneration must be within the contract agreement.

· No contract may commence unless the contract is signed by both UNICEF and the consultant or Contractor.

· For international consultants outside the duty station, signed contracts must be sent by fax or email. Signed contract copy or written agreement must be received by the office before Travel Authorisation is issued.

· No consultant may travel without a signed travel authorisation prior to the commencement of the journey to the duty station.

· Consultants will not have supervisory responsibilities or authority on UNICEF budget.

[1] Ghana Education Management Information System (EMIS) –

[2] Curtis V, Schmidt W, Florez R, Touré O and Biran A (2011) Hygiene: new hopes, new horizons. The

Lancet Infectious Diseases, vol 11, no 4, p 315

[3] Curtis V, Cairncross S (2003) Effect of washing hands with soap on diarrhoea risk in the community:

A systematic review. Lancet Infectious Diseases

[4] Fung I C H and Cairncross S (2009) Ascariasis and handwashing. Transactions of the Royal Society of

Tropical Medicine and Hygiene

[5]WELL (no date) Health impact of handwashing with soap [online]. Avalable at:

[6]Bartram J and Cairncross S (2010) Hygiene, sanitation, and water: Forgotten foundations of health.

PLoS Medicine

[7] Curtis V, Schmidt W, Florez R, Touré O and Biran A (2011) Hygiene: new hopes, new horizons. The

Lancet Infectious Diseases, vol 11

[8] Bartram J and Cairncross S (2010) Hygiene, sanitation, and water: Forgotten foundations of health.

PLoS Medicine, vol 7

[9] Right to Play/UNICEF (2015) Using Sport and Play to Enhance Quality and Sustainable Sanitation and Hygiene Practices: End-line Survey Report. Project document, Ghana

[10] Pobee-Hayford et al (2014) Mid-Term Review of the NORST Water and Sanitation Project. Project document, Ghana.

[11] Behaviours to be considered include handwashing with soap, safe excreta disposal, food hygiene, personal hygiene and cleanliness of the school environment

How to apply:

For Request For Proposal (RFP) contact the email address below;
[email protected].
[email protected].