The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006

The influence of an agricultural intervention on social capital and water insecurity coping strategies: Qualitative evidence from female smallholder farmers living with HIV in western Kenya

Background

Greater social capital is associated with positive health outcomes and better HIV management. The ways by which social capital may influence household water insecurity (HHWI), a critical determinant of health among persons living with HIV, remain underexplored. Further, despite the importance of reliable water access and use for health and agricultural productivity, few studies have described the strategies smallholder farmers living with HIV use to manage water insecurity.

Objective

We qualitatively explored how an agricultural intervention (provision of a treadle pump for irrigation) influenced HHWI coping strategies through its impacts on social capital among smallholder farmers living with HIV in western Kenya.

Method

In 2018, we purposively recruited participants from the Shamba Maisha study, a randomized agricultural intervention (NCT02815579) that provided irrigation pumps to improve treatment outcomes and food security among smallholder farmers living with HIV in western Kenya (n = 42). Participants shared their experiences with water insecurity through go-along and photo-elicitation interviews. Data were thematically analyzed using inductively developed codes.

Results

Participants described diverse strategies for coping with agricultural water insecurity. Dimensions of social capital such as feelings of belonging, connectedness, and trust influenced the use of the treadle water pump and other water access behaviors. For instance, participants reported borrowing or sharing water pumps with friends and neighbors if they felt they had a good rapport. In addition, participants indicated a willingness to engage in collective activities, such as supporting the operation of the irrigation pump during planting, when they felt sufficiently connected to a larger group. Overall, individuals in the intervention arm described greater social cohesion, reciprocity, and community connectedness than those in the control arm.

Conclusion

The impact of an agricultural intervention on water access and use was described as being modified by social capital among female smallholder farmers living with HIV. Findings suggest that social capital may create an enabling environment for implementing strategies that improve the management and reduce the burden of HIV. Measuring these strategies and their associations with HIV outcomes may strengthen our understanding of resilience among female smallholder farmers living with HIV. The development of a coping strategies index and its use in a longitudinal study could help to identify pathways through which social capital influences health and the effectiveness of livelihood interventions.

Improving Access to Safe Water in Rural Schools of Kenya: Qualitative Multisectoral Insights

BACKGROUND

Comprehensive strategies in water, sanitation, and appropriate hygiene behaviors can improve school enrolment and improve gender parity disparities. Lack of safe drinking water negatively impacts the social capital of people, especially school-going children in rural areas. In this study, we systematically evaluated and documented evidence on the barriers and facilitators in the access and adoption of safe water practices in rural schools in Laikipia County, Kenya.

METHODS

An ethnographic formative, collaborative implementation research design was used in an iterative and participatory process to evaluate community, socio-economic, and health system-related factors affecting water, hygiene, and sanitation strategies. Qualitative data was collected using key informant interviews (n=5) and focus groups (n=3) from various multisectoral participants. Directed content analysis was used to develop codes, categories, and themes from textual data. Data was organized according to the Promoting Action on Research Implementation in Health Services framework.

RESULTS

The findings were classified and described under three key elements: context, evidence, and facilitation. Contextual elements showed an association of diarrhea outbreaks with unsafe hygiene practices compounded by water scarcity. The evidence elements were indicative of the applicability of water backpacks in strengthening handwashing, storage, and transport of water. Facilitation elements indicated evidence of gaps in synergy between the school health and public health systems, necessitating multisectoral collaboration and social capital capacity building.

CONCLUSION

The national and county governments play an imperative role in ensuring access and continuous supply of safe drinking water in schools. This is fundamental in efforts towards reducing social inequalities of health among school-going children and building their social capital. Participatory, collaborative, multisectoral interventions and decision-making are crucial, leveraging on creating local ownership, in meeting the water consumption needs of children and communities in water-scarce regions.

Assessing Access to WASH in Urban Schools during COVID-19 in Kazakhstan: Case Study of Central Kazakhstan

The WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation and Hygiene (WASH) produces global estimates of the real situation of access to water, sanitation and hygiene services, and sanitation and hygiene in households, educational institutes and health care facilities; however it is lacking data on schools in Kazakhstan. Thus, the aim of this research was to assess access to WASH in schools of urban area in Kazakhstan. The study was conducted in seven schools of Central Kazakhstan during the COVID-19 pandemic and restrictive measures. Three data collection methods were used: a questionnaire for administrative staff, a questionnaire for parents and observation. Parents of offline study pupils (only second and third grades due to the pandemic) were included in the survey. Students had access to in-building toilets in all schools connected to the centralized sewer. The number of school toilets varied from 7 (KAZ200085) to 61 (KAZ200089). The average amount of toilets was 28.08 ± 16.97. Only two out of seven schools complied with the requirements of Kazakhstan national sanitary standards for the ratio of school toilets to the number of students. From the questionnaire with the school administrations, it was defined that the primary source of drinking water was the public water supply. All schools regularly disinfect and check the water supply system. At the same time, the results also revealed discrepancies in the answers between administration and parents (2.6% of parents showed that their children have rare access to drinking water), and insufficient monitoring of implementation of WASH services. This study also confirmed that the full provision of access to water and water services in the structure of educational institutions solves several SDG targets.

Feature importance: Opening a soil-transmitted helminth machine learning model via SHAP

In the field of landscape epidemiology, the contribution of machine learning (ML) to modeling of epidemiological risk scenarios presents itself as a good alternative. This study aims to break with the ”black box” paradigm that underlies the application of automatic learning techniques by using SHAP to determine the contribution of each variable in ML models applied to geospatial health, using the prevalence of hookworms, intestinal parasites, in Ethiopia, where they are widely distributed; the country bears the third-highest burden of hookworm in Sub-Saharan Africa. XGBoost software was used, a very popular ML model, to fit and analyze the data. The Python SHAP library was used to understand the importance in the trained model, of the variables for predictions. The description of the contribution of these variables on a particular prediction was obtained, using different types of plot methods. The results show that the ML models are superior to the classical statistical models; not only demonstrating similar results but also explaining, by using the SHAP package, the influence and interactions between the variables in the generated models. This analysis provides information to help understand the epidemiological problem presented and provides a tool for similar studies.

Effect of school-based educational water, sanitation, and hygiene intervention on student's knowledge in a resource-limited setting

BACKGROUND

Globally, diarrhea is one of the major causes of under-5 mortality. India accounts for the highest number of childhood deaths from diarrhea globally. Therefore, facilitating the implementation of water, sanitation, and hygiene (WASH)-related interventions in schools and communities is crucial. In the present study, we investigated the effectiveness of a school-based educational WASH intervention in improving students' knowledge on prevention and management of diarrhea in Ujjain district, India.

METHODS

The present pre-post intervention study with a two-stage (schools and classrooms) cluster sampling was conducted on 1,781 students studying in grades: 8^th-12^th; age: 14-19 years) in schools located in Ujjain, Madhya Pradesh, India. The intervention comprised an educational training session using a WASH training module. The means of pre- and post-intervention scores were compared using repeated measure analysis of variance. A multivariate quantile regression model was used to test the correlation between the change in score after intervention and the independent variables. A P value of <0.05 was considered statistically significant.

RESULTS

The proportions of students possessing knowledge on the treatment of diarrhea, use of zinc tablets during an episode of diarrhea, and the symptoms and signs of severe pediatric diarrhea were 28%, 27%, and 27%, respectively, before intervention. These proportions increased (P<0.001) after the educational intervention to 72%, 73%, and 74%, respectively. The mean post-intervention knowledge score (34.13) was higher than the mean pre-intervention score (15.17) (F = 16513.36, P< 0.001). Age was associated with the knowledge score at the 25^th and higher quantile (q). Gender exhibited a greater effect at q10^th. School location was positively associated at q25^th and higher. School type was strongly associated at low quantiles (q10^th and q25^th). School medium exhibited a greater association at low quantiles (≤q25^th).

CONCLUSION

WASH- and diarrhea-related knowledge among higher secondary school students increased after the educational intervention. Further research is required to evaluate the sociodemographic characteristics associated with change in the knowledge score to better evaluate school-based educational WASH interventions and improve the management and prevention of diarrhea.

Mapping and situation analysis of basic WASH facilities at households in Bangladesh: Evidence from a nationally representative survey

BACKGROUND

Ensuring water, sanitation, and hygiene (WASH) facilities for households remains a major public health concern in low- and middle-income countries (LMICs). This study investigated the current situation of basic WASH facilities for households in Bangladesh and drew a national coverage map.

METHODS

We analyzed the publicly available nationally representative 2019 Multiple Indicator Cluster Survey (MICS) dataset that was carried out by the Bangladesh Bureau of Statistics (BBS) with support from the United Nations Children's Emergency Fund (UNICEF). A total of 61,209 households (weighted) were included in the analysis. Both bivariate and multivariate analyses were employed to examine the relationships between independent variables (socio-demographic and economic status) and their distributions over outcome variables (basic water, sanitation, and hygiene). Further, the spatial distribution of WASH facilities at the household level was depicted.

RESULTS

Coverage of access to basic water facilities at the household level was 99.5% (95% CI 99.4% to 99.6%), sanitation 60.7% (95% CI 60.0% to 61.5%), and hygiene 56.3% (95% CI 55.6% to 57.0%). However, coverage of combined access to all three components was 40.2% (95% CI 39.4% to 40.9%). Among all 64 administrative districts of Bangladesh, we found comparatively lower coverage of WASH facilities in the South and South-East regions and relatively higher in the households of the North and North-Western regions. An adjusted regression model revealed that richest households [AOR = 29.64, 95% CI 26.31 to 33.39], households in the rural areas [AOR = 1.64, 95% CI 1.50 to 1.79], household heads with higher educational attainment [AOR = 2.28, 95% CI 2.09 to 2.49], and households with 5+ family members [AOR = 1.64, 95% CI 1.56 to 1.71] had the higher likelihood to have basic WASH facilities.

CONCLUSION

Less than half of the Bangladeshi households had access to all three major WASH components (basic water, sanitation, and hygiene facilities); however, variation exists at the individual parameter of basic water, sanitation, and hygiene facilities. A comprehensive WASH approach may reduce the gap and improve the quality of WASH facilities in Bangladesh.

The potential of school-based WASH programming to support children as agents of change in rural Zambian households

Background

Water, sanitation, and hygiene (WASH) interventions frequently assume that students who learn positive WASH behaviors will disseminate this information to their families. This is most prominent in school-based programs, which rely on students to act as “agents of change” to translate impact from school to home. However, there is little evidence to support or contradict this assumption.

Methods

We conducted a quasi-experimental, prospective cohort study in 12 schools in rural, southern Zambia to measure the impact of WASH UP!, a school-based WASH program designed by the creators of Sesame Street. WASH UP! is an educational program that uses stories and interactive games to teach students in grades 1–4 about healthy behaviors, such as washing hands and using the latrine. We completed in-person interviews with grade 1 and 4 students (N = 392 and 369, respectively), their teachers (N = 24) and caregivers (N = 729) using structured surveys containing both open- and closed-ended questions. We measured changes in knowledge and whether students reported sharing WASH-related messages learned in school with their caregivers at home.

Results

Student knowledge increased significantly, but primarily among students in grade 1. Overall rates of students reporting that they shared messages from the curriculum with their caregivers rose from 7 to 23% (p <  0.001). Students in grade 4 were 5.2 times as likely as those in grade 1 to report sharing a WASH-related message with their caregivers (ARR = 5.2, 95% C.I. = (2.3, 8.9); p <  0.001).

Conclusions

Although we measured only modest levels of student dissemination of WASH UP! messages from the school to the home, students in grade 4 showed significantly more promise as agents of change than those in grade 1. Future work should prioritize developing curricula that reflect the variability in needs, capabilities and support in the home and community among primary school students rather than a single approach for a wide range of ages and contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11824-3.

Handwashing Knowledge, Attitudes, and Practices among Students in Eastern Province Schools, Saudi Arabia

Background. Lack of knowledge about appropriate handwashing practices has caused great concerns for human health, especially in the risk of many communicable diseases. The objective of the current study is to determine the level of handwashing knowledge, attitudes, and practices among school students in Eastern Province Schools, Saudi Arabia. A cross-sectional survey was recruited from November 2019 to March 2020 to assess the level of the students' handwashing knowledge. A reliable questionnaire was prepared (Cronbach's alpha = 0.608) and conducted using a two-stage sampling technique. A total of 271 students participated in the study from primary, middle, and high schools; 80% were boys, most of whom displayed an acceptable level of knowledge on hand hygiene. Nearly 75% and 74% of boys and girls, respectively, gained knowledge about hand hygiene practices from their parents. Only 46% of the students thought that handwashing is a potential protective measure against diseases, whereas 34% thought it only removes dirt. Prevalence of handwashing with soap after using the toilet was recognized among 52% of the students. Additionally, 93% of the students used water and soap to wash their hands (p value < 0.001) and 97% suggested that soap and water are the best methods to wash their hands (p value < 0.001). There was a positive correlation between the mother's education and hand hygiene practices (p value = 0.044). Results collectively indicated that handwashing knowledge and practices among school students in the Eastern Province are acceptable interventions in preventing the transmission of infectious diseases such as COVID-19. Indeed, further improvement conducted through specific health education programs to emphasize the role of handwashing in health hygiene is highly recommended.

Characteristics of sanitation and hygiene facilities in a slum community in Kampala, Uganda

Background

This study assessed characteristics of sanitation and hygiene facilities in a slum community in Kampala, Uganda.

Methods

We conducted a household-based cross-sectional study among 395 households in Kasubi slum using a semi-structured questionnaire and observational checklist to collect data.

Results

Almost 98.0% (387/395) of households owned a sanitation facility and 77.0% (298/387) shared it with other households. The most common type of sanitation facility was a pit latrine with slab (66.9% [259/387]). Most (90.5% [305/337]) latrines had a door or shutter, a roof (92.9% [313/337]) and a depth >1.5 m (68.2% [229/337]). Overall, 21.3% (84/395) and 65.6% (259/395) of households had improved and functional sanitation facilities, respectively. Only 16.5% (65/395) of the households had a hand-washing facility. Student-led (adjusted prevalence rate [PR] 2.67 [95% confidence interval [CI] 1.83–3.94]) and households that owned their house (adjusted PR 2.17 [95% CI 1.33–3.53]) were 2.67 and 2.17 times more likely to have improved sanitation facilities, respectively. Households that owned their house (adjusted PR 1.90 [95% CI 1.18–3.05]) were 1.9 times more likely to possess a hand-washing facility.

Conclusions

The coverage of improved sanitation and hygiene facilities was low. The majority of households were using a shared pit latrine with a slab that had no hand-washing facility. Sanitation and hygiene interventions should prioritize improving sanitation and hygiene facilities.

Kenyan school book knowledge for water, sanitation, hygiene and health education interventions: Disconnect, integration or opportunities?

BACKGROUND

Schools, depending on their access to and quality of water, sanitation and hygiene (WASH) and the implementation of healthy behaviours, can be critical for the control and spread of many infectious diseases, including COVID-19. Schools provide opportunities for pupils to learn about the importance of hygiene and WASH-related practice, and build healthy habits and skills, with beneficial medium- and long-term consequences particularly in low- and middle-income countries: reducing pupils' absenteeism due to diseases, promoting physical, mental and social health, and improving learning outcomes. WASH services alone are often not sufficient and need to be combined with educational programmes. As pupils disseminate their acquired health-promoting knowledge to their (extended) families, improved WASH provisions and education in schools have beneficial effects also on the community. International organisations frequently roll out interventions in schools to improve WASH services and, in some cases, train pupils and teachers on safe WASH behaviours. How such interventions relate to local school education on WASH, health promotion and disease prevention knowledge, whether and how such knowledge and school books are integrated into WASH education interventions in schools, are knowledge gaps we fill.

METHODS

We analyzed how Kenyan primary school science text book content supports WASH and health education by a book review including books used from class 1 through class 8, covering the age range from 6 to 13 years. We then conducted a rapid literature review of combined WASH interventions that included a behaviour change or educational component, and a rapid review of international policy guidance documents to contextualise the results and understand the relevance of books and school education for WASH interventions implemented by international organisations. We conducted a content analysis based on five identified thematic categories, including drinking water, sanitation, hygiene, environmental hygiene & health promotion and disease risks, and mapped over time the knowledge about WASH and disease prevention.

RESULTS

The books comprehensively address drinking water issues, including sources, quality, treatment, safe storage and water conservation; risks and transmission pathways of various waterborne (Cholera, Typhoid fever), water-based (Bilharzia), vector-related (Malaria) and other communicable diseases (Tuberculosis); and the importance of environmental hygiene and health promotion. The content is broadly in line with internationally recommended WASH topics and learning objectives. Gaps remain on personal hygiene and handwashing, including menstrual hygiene, sanitation education, and related health risks and disease exposures. The depth of content varies greatly over time and across the different classes. Such locally available education materials already used in schools were considered by none of the WASH education interventions in the considered intervention studies.

CONCLUSIONS

The thematic gaps/under-representations in books that we identified, namely sanitation, hygiene and menstrual hygiene education, are all high on the international WASH agenda, and need to be filled especially now, in the context of the current COVID-19 pandemic. Disconnects exist between school book knowledge and WASH education interventions, between policy and implementation, and between theory and practice, revealing missed opportunities for effective and sustainable behaviour change, and underlining the need for better integration. Considering existing local educational materials and knowledge may facilitate the buy-in and involvement of teachers and school managers in strengthening education and implementing improvements. We suggest opportunities for future research, behaviour change interventions and decision-making to improve WASH in schools.

Impact of hand hygiene intervention on hand washing ability of school-aged children

BACKGROUND

To assess the current knowledge related to hand washing and efficiency of intervention on hand washing techniques amongst school children.

METHODOLOGY

A randomized control trial was conducted amongst class II students of a private school in Korangi, Karachi. Pre-intervention assessment including baseline knowledge and observed practices of hand washing in comparison with World Health Organization (WHO) standard hand washing techniques was done. This was followed by education and demonstration of proper hand washing steps by principal investigator utilizing visual aids. Participants were then randomized into two group: Group A (education only group) and Group B (education along with glow gel application group). First post-intervention assessment was conducted on same day where both groups were observed for the hand washing steps and scored for hand washing technique. In addition, participants of group B were shown germs under Ultraviolet (UV) light. School was revisited after 1 week later and participants were reassessed for their hand washing technique along with cleanliness grade after applying glow gel and observing under UV light. Data was entered and analyzed using SPSS version 21.0.

RESULT

No significant differences were found in median hand washing scores pre-intervention between both the groups (Group A vs B: 4 vs 5, P value = 0.659), while significant improvement in median hand washing scores was seen post intervention in group B as compared to group A (7 vs 6, P value = 0.011). However, no significant differences were seen in median hand washing scores at follow-up between both the groups (Group A vs B: 9 vs 8.5, P value = 0.715) but a significant improvement was observed in both the groups in the hand washing practices from baseline (P-value = 0.000). On the contrary, no significant differences were found in median cleanliness grade between both the groups (Median for both the groups was 5, P value = 0.695).

CONCLUSIONS

Hand washing education utilizing various aids is an effective method to improve children's hand washing capability. This short-term intervention was effective even in absence of glow gel, but no cleanliness of hands was observed in both the groups.

Evaluating children's handwashing in schools: an integrative review of indicative measures and measurement tools

Children are a key target of handwashing interventions as washing hands reduces the spread of disease and reliance on antibiotics. While there is guidance for evaluating handwashing with adults in other settings, this is lacking for children in schools. An integrative review of 65 studies where handwashing was measured in schools was conducted to establish which indicative measures (what is measured to evaluate the processes and/or impacts of, handwashing) and measurement tools (data collection instruments) have been applied to evaluate handwashing in schools, and under what circumstances. Further analysis highlighted different challenges when seeking to apply such measures and tools in schools, as opposed to other settings. It was concluded that indicative measures, and measurement tools need to be appropriate to the organizational setting, the study participants, and research objectives. A summative analysis of relevant considerations is presented.

Implementation of Kenyan comprehensive school health program: improvement and association with students' academic attainment

There is growing evidence supporting the effectiveness of a comprehensive school health program. However, implementation in developing countries is a challenge. Furthermore, the available information on the association between a comprehensive school health program and students' academic attainment is limited. In Kenya, a project to verify the effects of a comprehensive school health program was carried out in Mbita sub-county, Homa Bay County from September 2012 to August 2017. This study aimed to clarify the improvement of school health during the project years and the association between school health and students' academic attainment. Primary schools in Mbita sub-county were selected as study sites. We assessed 44 schools' scores on a school health checklist developed from the Kenyan Comprehensive School Health Program, the students' mean score on the Kenya Certificate of Primary Education (KCPE), and absenteeism during the project years (2013-16). The mean school health checklist score (n = 44 schools) was 135.6 in 2013, 169.9 in 2014, 158.2 in 2015 and 181.3 in 2016. The difference of the mean score between 2013 and 2016 was significant. In addition, correlation analysis showed a significant association between mean KCPE score in the project years and school health checklist score (Pearson's coefficient was 0.43, p = 0.004). The results of this study suggest improvements of school health by the implementation of the Kenyan Comprehensive School Health Program and students' academic attainment.

Evaluation of hand hygiene behaviour in basic schools in Ghana: a case study of the Ablekuma Central Municipality in the greater region of Ghana

Hand washing is effective for the prevention and transmission of pathogens but washing with water only is not effective at reducing contamination. The study focussed on the evaluation of hand washing behaviour in Basic schools (Primary and Junior High Schools) in Ghana. Results of the study revealed that 75% of responding schools have hand washing stands to promote hand washing with soap. Sixty percent of the hand washing facilities were functional at the time of the study in the schools. Hand washing facilities were found to be inadequate as most of the schools lacked running water and soap for hand washing. The school children (72%) were found to have knowledge on hand hygiene. The school children were aware that they can get cholera, typhoid fever, dysentery, diarrhoea, stomach cramps and pains when they do not wash their hands with soap. Majority (68.2%) of school children reported that washing hands after defecation is important but only 17.5% reported actually follow this practice. The school children (51%) reported washing their hands before eating. Many of the schools did not have toilet facilities for the school children. The school children (35%) learnt hand washing from their parents and 60% from the teachers.

Examining the appropriateness and reliability of the strategy of the Kenyan Comprehensive School Health Program

The Kenyan government established the Kenyan Comprehensive School Health Program (KCSHP) on the basis of Kenyan National School Health Policy. A KCSHP pilot project was carried out in eight primary schools in Mbita Sub-County of Homa Bay County in the Nyanza Region from 2012 to 2017. This pilot project provided health facilities and support for evaluation with a school health checklist, and organized teacher training on health education, a child health club, and school-based health check-ups. The present study aimed to examine the appropriateness and reliability of the strategy of the second KCSHP pilot project in Kenya. We analyzed data from self-administered questionnaires targeted at pupils in seventh-grade in the eight primary schools. The questionnaire consisted of questions on health-related knowledge, attitudes and practices, self-evaluated physical and mental health status, self-awareness of health control, subjective happiness, recognition on the importance of learning about health in school, absenteeism, and sense of school belongingness. The project contributed to improving health-related knowledge, attitudes and practices, self-evaluated health status, sense of school belongingness, recognition on the importance of learning about health in school, self-awareness of health control, and absenteeism. On the contrary, subjective happiness did not improve significantly.

Use, Acceptability, Performance, and Health Impact of Hollow Fiber Ultrafilters for Water Treatment in Rural Kenyan Households, 2009-2011

Diarrheal illness remains a leading cause of morbidity and mortality in children < 5 years in developing countries, and contaminated water contributes to diarrhea risk. To address this problem, a novel hollow fiber ultrafilter (HFU) was developed for household water treatment. To test its impact on water quality and infant health, we conducted a cluster-randomized longitudinal evaluation in 10 intervention and 10 comparison villages in Kenya, attempting to enroll all households with infants (< 12 months old). We conducted a baseline survey, distributed HFUs to intervention households, made biweekly home visits for 1 year to assess water treatment practices and diarrhea in infants, and tested water samples from both groups every 2 months for Escherichia coli. We enrolled 92 infants from intervention households and 74 from comparison households. During the 1-year study period, 45.7% of intervention households and 97.3% of comparison households had at least one stored water sample test positive for E. coli. Compared with comparison households, the odds of E. coli contamination in stored water was lower for intervention households (odds ratio [OR]: 0.42, 95% CI: 0.24, 0.74), but there was no difference in the odds of reported diarrhea in infants, adjusting for covariates (OR: 1.19, 95% CI: 0.74, 1.90). Although nearly all water samples obtained from unprotected sources and filtered by the HFU were free of E. coli contamination, HFUs alone were not effective at reducing diarrhea in infants.

Impact of a teacher-led school handwashing program on children's handwashing with soap at school and home in Bihar, India

Handwashing with soap is an important preventive health behavior, and yet promoting this behavior has proven challenging. We report the results of a program that trained teachers to deliver a handwashing with soap behavior change program to children in primary schools in Bihar, India. Ten intervention schools selected along with ten nearby control schools, and intervention schools received the “School of Five” program promoting handwashing with soap using interactive stories, games, and songs, behavioral diaries to encourage habit formation, and public commitment. Households with children aged 8–13 attending the nearby school were enrolled in the study. Handwashing with soap was measured using sticker diaries before eating and after defecation 4 weeks after the intervention was completed. Children in the treatment reported 15.1% more handwashing with soap on key occasions (35.2%) than those in the control group (20.1%) (RR: 1.77, CI: (1.22, 2.58), p = .003). There was no evidence that handwashing with soap after defecation was higher in the treatment group than the control group (RR: 1.18, CI: (0.88, 1.57), p = .265), but there was strong evidence that handwashing with soap was greater in the treatment than in the control before eating (RR: 2.68, 95% CI: (1.43, 5.03), p = .002). Rates of handwashing increased both at home (RR: 1.63, CI: 1.14, 2.32), p = .007) and at school (RR: 4.76, 95% CI: (1.65, 17.9), p = .004), though the impact on handwashing with soap at key occasions in schools was much higher than at home. Promoting handwashing with soap through teachers in schools may be an effective way to achieve behavior change at scale.

Risk map development for soil-transmitted helminth infections in Argentina

BACKGROUND

Soil-transmitted helminths (STHs) comprise a group of helminth parasites that are included in the list of Neglected Tropical Diseases and require a passage through the soil to become infective. Several studies have detected that infection with STHs are associated with certain socioeconomic, environmental and soil characteristics. In Argentina, the presence of these parasites has been detected through a few point studies conducted in localities from 11 of the 23 provinces that comprise the country.

METHODS/PRINCIPAL FINDINGS

The most important characteristics previously associated with the presence of STHs were identified and ranked through the use of an expert survey and the Analytical Hierarchy Process (AHP) in order to construct a risk map of STHs specific for Argentina. Prevalence data from previous studies was used to validate the generated risk map. The map shows that half of Argentina, from the Central provinces to the North, contains localities with the characteristics necessary for the development of these parasites.

CONCLUSIONS/SIGNIFICANCE

The predicted map should serve as a useful tool for guiding the identification of survey areas for the generation of baseline data, detecting hotspots of infection, planning and prioritizing areas for control interventions, and eventually performing post-implementation surveillance activities.

Evidence of Households' Water, Sanitation, and Hygiene (WASH) Performance Improvement Following a WASH Education Program in Rural Dembiya, Northwest Ethiopia

BACKGROUND

Water, Sanitation, and Hygiene (WASH) promotion is a viable solution to prevent enteric infections. It focuses on hygiene education, where a number of theoretical models have emerged which attempt to guide behavior change interventions. This study was, therefore, conducted to evaluate the effectiveness WASH education program on households' WASH performance in rural Dembiya, northwest Ethiopia.

METHOD

An uncontrolled before-and-after intervention study was conducted. Baseline and endline surveys were done among 225 and 302 randomly selected households with under-5 children, respectively, using a structured questionnaire and observational checklists. Percent point change was used to see the effect of the intervention. Pearson χ² and Fisher exact tests were used to test for statistically significant percentage point changes on the basis of P < .05.

RESULT

Access to adequate sanitation was significantly improved from 43.1% at the baseline to 50.7% at the endline (P < .05). Access to protected water sources was high at the baseline (73.8%) and remained high (81.1%) at the endline (P < .05). Significant proportion of households (58.3%) practiced good drinking water handling at the endline compared with the baseline (6.7%) (P < .001). Practice of home-based water treatment was improved at the endline (47%) compared with the baseline (7.6%) (P < .001). The general hygienic condition of children was significantly improved at the end of the intervention compared with the conditions before the intervention (P < .05). At the end of the intervention, mothers' hand washing practice was improved to 68.2% from 24.4% at the baseline (P < .001). Moreover, 52.4% and 69.5% of the households at the baseline and endline, respectively, had good food safety practice (P < .05).

CONCLUSION

The proportion of households who practiced water safety, basic sanitation, good personal hygiene, and basic food safety measures significantly increased at the endline. This significant increment clearly showed that our WASH interventions were effective to improve households' WASH performance in rural Dembiya. The local health office need, therefore, strengthens the WASH education program.

The Impact of a School-Based Water, Sanitation and Hygiene Intervention on Knowledge, Practices, and Diarrhoea Rates in the Philippines

A school-based water, sanitation, and hygiene (WASH) intervention in the Philippines was evaluated. Students and households from four schools that received the WASH intervention (intervention schools) were compared with four schools that had not (comparison schools). Knowledge of critical handwashing times was high across all schools, but higher in intervention schools. Students reported higher rates of handwashing after toilet use (92% vs. 87%; RR = 1.06; p = 0.003) and handwashing with soap (83% vs. 60%; RR = 1.4; p < 0.001) in intervention versus comparison schools. In intervention schools, 89% of students were directly observed to handwash after toilet use versus 31% in comparison schools (RR = 2.84; p < 0.0001). Observed differences in handwashing with soap after toilet use were particularly marked (65% vs. 10%; RR = 6.5; p < 0.0001). Reported use of school toilets to defecate (as opposed to use of toilet elsewhere or open defecation) was higher among intervention versus comparison schools (90% vs. 63%; RR = 1.4; p < 0.001). Multilevel modelling indicated that students from intervention schools reported a 10-fold reduction in odds (p < 0.001) of school absence due to diarrhoea. In addition to school-based findings, self-reported handwashing at critical times was found to be higher among household members of students from intervention schools. This school-based WASH program appeared to increase knowledge and hygiene behaviours of school students, reduce absences due to diarrhoea, and increase handwashing at critical times among household members.

Water, Sanitation, and Hygiene Characteristics among HIV-Positive Households Participating in the Global Enteric Multicenter Study in Rural Western Kenya, 2008-2012

Diarrheal illness, a common occurrence among people living with human immunodeficiency virus (PLHIV), is largely preventable through access to safe drinking water quality, sanitation, and hygiene (WASH) facilities. We examined WASH characteristics among households with and without HIV-positive residents enrolled in the Global Enteric Multicenter Study (GEMS) in rural Western Kenya. Using univariable logistic regression, we examined differences between HIV-positive and HIV-negative households in regard to WASH practices. Among HIV-positive households, we explored the relationship between the length of time knowing their HIV status and GEMS enrollment. No statistically significant differences were apparent in the WASH characteristics among HIV-positive and HIV-negative households. However, we found differences in the WASH characteristics among HIV-positive households who were aware of their HIV status ≥ 30 days before enrollment compared with HIV-positive households who found out their status < 30 days before enrollment or thereafter. Significantly more households aware of their HIV-positive status before enrollment reported treating their drinking water (odds ratio [OR] confidence interval [CI]: 2.34 [1.12, 4.86]) and using effective water treatment methods (OR [CI]: 9.6 [3.09, 29.86]), and had better drinking water storage practices. This suggests that within this region of Kenya, HIV programs are effective in promoting the importance of practicing positive WASH-related behaviors among PLHIV.

Effect of a School-Based Hygiene Behavior Change Campaign on Handwashing with Soap in Bihar, India: Cluster-Randomized Trial

Changing hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever’s school-based “School of 5” handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts. We randomized a total of 32 villages with at least one eligible school to intervention and control groups (1:1) and recruited 338 households in each group for outcome measurement. We used structured observation in households to measure HWWS at target occasions (after defecation, soap use during bathing, and before each main meal) in schoolchildren and their mothers. Observers were blinded to intervention status. We observed 636 target occasions (297 in the intervention arm and 339 in the control arm) in mothers and school-going children. After the intervention, HWWS prevalence at target occasions was 22.4% in the control arm and 26.6% in the intervention arm (prevalence difference +4.4%, 95% confidence interval: −4.0, 12.8). The difference was similar in children and mothers. Observers appeared to be adequately blinded to intervention status, whereas observed households were successfully kept unaware of the purpose of observations. To conclude, we found no evidence for a health-relevant effect of the School of 5 intervention on HWWS in schoolchildren and their mothers. Qualitative research suggested that reasons for the low impact of the intervention included low campaign intensity, ineffective delivery, and a model possibly not well tailored to these challenging physical and social environments.

Knowledge and practices of households on safe water chain maintenance in a slum community in Kampala City, Uganda

Background

More than half of the disease burden in Uganda can be prevented through improving water, sanitation, and hygiene (WASH). In slum communities, water supply is insufficient but also highly contaminated; therefore, ensuring that the safe water chain is maintained by households is paramount to preventing water-related diseases. This study aimed at assessing knowledge and practices of households on safe water chain maintenance in slum communities in Kampala City, Uganda.

Methods

This was a community-based cross-sectional study carried out among 395 households in slum communities in Kampala, Uganda. Data were collected using a semi-structured questionnaire. Prevalence ratios (PRs) and their 95% confidence intervals were used as a measure of association between safe water chain management and associated knowledge and practice factors. The PRs were obtained using a multivariable modified Poisson regression with logarithm as the link function, with robust standard errors.

Results

Majority (76.7%, 303/395) of the households collected their water from a piped water system and paid for the water (72.9%, 288/395). Almost all (97.2%, 384/395) of the participants said that they knew the dangers associated with drinking unsafe water, boiled their drinking water (95.4%, 377/395), and used storage containers that minimize contamination (97.0%, 383/395). However, only (32.4%, 128/395) of the households satisfactorily maintained the safe water chain. Female- (adjusted PR = 1.82, 95% CI (1.19–2.78)) and student-led households (adjusted PR = 1.58, 95% CI (1.03–2.41)) and those whose heads had attained post-primary education (adjusted PR = 1.48, 95% CI (1.02–2.17)) were more likely to satisfactorily maintain the safe water chain. This was similar among members who thought most contamination occurs during storage (adjusted PR = 1.47, 95% CI (1.10–1.97)).

Conclusion

Only a third of the households maintained the safe water chain satisfactory. Female-led, student-led, and post-primary educated-led household and household that thought most contamination occurs during storage were more likely to maintain the safe water chain. There is a need to improve the level of awareness about the importance of the safe water chain among slum dwellers.

Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact

Many schools in low-income countries have inadequate access to water facilities, sanitation and hygiene promotion. A systematic review of literature was carried out that aimed to identify and analyse the impact of water, sanitation and hygiene interventions (WASH) in schools in low-income countries. Published peer reviewed literature was systematically screened during March to June 2018 using the databases PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google Scholar. There were no publication date restrictions. Thirty-eight peer reviewed papers were identified that met the inclusion criteria. The papers were analysed in groups, based on four categories of reported outcomes: (i) reduction of diarrhoeal disease and other hygiene-related diseases in school students; (ii) improved WASH knowledge, attitudes and hygiene behaviours among students; (iii) reduced disease burden and improved hygiene behaviours in students' households and communities; (iv) improved student enrolment and attendance. The typically unmeasured and unreported 'output' and/or 'exposure' of program fidelity and adherence was also examined. Several studies provide evidence of positive disease-related outcomes among students, yet other assessments did not find statistically significant differences in health or indicated that outcomes are dependent on the nature and context of interventions. Thirteen studies provide evidence of changes in WASH knowledge, attitudes and behaviours, such as hand-washing with soap. Further research is required to understand whether and how school-based WASH interventions might improve hygiene habits and health among wider family and community members. Evidence of the impact of school-based WASH programs in reducing student absence from school was mixed. Ensuring access to safe and sufficient water and sanitation and hygiene promotion in schools has great potential to improve health and education and to contribute to inclusion and equity, yet delivering school-based WASH intervention does not guarantee good outcomes. While further rigorous research will be of value, political will and effective interventions with high program fidelity are also key.

Impact of a Hand Hygiene Curriculum and Group Handwashing Station at Two Primary Schools in East Africa

Proper handwashing reduces the transmission of deadly, preventable diseases. Schools, even those with limited resources, have the power to promote handwashing through simple, effective interventions. This study evaluated the impact of a school-based handwashing program consisting of two interventions: a hand-hygiene curriculum and group handwashing station. Quantitative and open-ended pre/postintervention surveys were administered to students at one primary school in Kenya ( n = 38) and at one primary school in Uganda ( n = 57). Matching procedures were followed at each school. Paired ttests for pre/postsurveys demonstrated an increase in students’ knowledge ( p < .001) and frequency of handwashing ( p < .001). After 6 months, students were still engaging in daily group handwashing. The curriculum increased knowledge, and the handwashing station enabled students to translate their knowledge into action. This study supports educational interventions combined with built environmental interventions should be used to promote handwashing behaviors and emphasizes the role of group handwashing stations.

'I know how stressful it is to lack water!' Exploring the lived experiences of household water insecurity among pregnant and postpartum women in western Kenya

There is rapidly evolving literature on water insecurity in the general adult population, but the role of water insecurity during the vulnerable periods of pregnancy and postpartum, or in the context of HIV, has been largely overlooked. Therefore, we conducted an exploratory study, using Go Along interviews, photo-elicitation interviews, and pile sorts with 40 pregnant and postpartum Kenyan women living in an area of high HIV prevalence. We sought to (1) describe their lived experiences of water acquisition, prioritisation, and use and (2) explore the consequences of water insecurity. The results suggest that water insecurity is particularly acute in this period, and impacts women in far-reaching and unexpected ways. We propose a broader conceptualisation of water insecurity to include consideration of the consequences of water insecurity for maternal and infant psychosocial and physical health, nutrition, and economic well-being.

Water treatment and handwashing practices in rural Kenyan health care facilities and households six years after the installation of portable water stations and hygiene training

Many health care facilities (HCFs) and households in low-and-middle-income countries have inadequate access to water for hygiene and consumption. To address these problems, handwashing and drinking water stations were installed in 53 HCFs with prevention-of-mother-to-child-transmission of HIV programs in Kenya in 2005, and hygiene education was provided to health workers and clinic clients. To assess this program, we selected a random sample of 30 HCFs, observed the percentage of handwashing and drinking water stations that were functional and in use, and after that interviewed health providers and clients about hygiene and water treatment. Results indicated that, six years after implementation, 80.0% of HCFs had at least one functional handwashing station and 83.3% had at least one functional drinking water station. In addition, 60% of HCFs had soap at ≥ one handwashing stations, and 23.3% had ≥ one container with detectable free chlorine. Of 299 clients (mothers with ≥ one child under five), 57.2% demonstrated proper water treatment knowledge, 93.3% reported ever using water treatment products, 16.4% had detectable chlorine residual in stored water, and 89.0% demonstrated proper handwashing technique. Six years after program implementation, although most HCFs had water stations and most clients could demonstrate proper handwashing technique, water stored in most clinics and homes was not treated.

Drinking Water Supply, Sanitation, and Hygiene Promotion Interventions in Two Slum Communities in Central Uganda

Poor water, sanitation, and hygiene (WASH) continue to contribute to the high prevalence of diarrhoeal diseases in low-income countries such as Uganda particularly in slums. We implemented a 3-year WASH project in two urban slums in Uganda with a focus on safe drinking water and improvement in sanitation. The project implemented community and school interventions in addition to capacity building initiatives. Community interventions included home improvement campaigns, clean-up exercises, water quality assessment, promotion of drinking safe water through household point-of-use chlorination, promotion of hand washing, and support towards solid waste management. In schools, the project supported health clubs and provided them with "talking compound" messages. The capacity building initiatives undertaken included training of youth and community health workers. Project evaluation revealed several improvements in WASH status of the slums including increase in piped water usage from 38% to 86%, reduction in use of unprotected water sources from 30% to 2%, reduction in indiscriminate disposal of solid waste from 18% to 2%, and increase in satisfaction with solid waste management services from 40% to 92%. Such proactive and sustainable community interventions have the potential to not only improve lives of slum inhabitants in developing countries but also create lasting impact.

Impact of maternal common mental disorders on child educational outcomes at 7 and 9 years: a population-based cohort study in Ethiopia

OBJECTIVES

To examine the association between exposure to maternal common mental disorders (CMD) in preschool and early school age children and subsequent child educational outcomes.

DESIGN

A population-based cohort study.

SETTING

The study was undertaken in the Butajira health and demographic surveillance site (HDSS), a predominantly rural area of south central Ethiopia.

PARTICIPANTS

Inclusion criteria are women aged between 15 and 49 years, able to speak Amharic, in the third trimester of pregnancy and resident of the HDSS. 1065 women were recruited between July 2005 and February 2006 and followed up. When the average age of children was 6.5 years old, the cohort was expanded to include an additional 1345 mothers and children who had been born in the 12 months preceding and following the recruitment of the original cohort, identified from the HDSS records. Data from a total of 2090 mother-child dyads were included in the current analysis.

MEASURES

Maternal CMD was measured when the children were 6-7 (6/7) and 7-8 (7/8) years old using the Self-reporting Questionnaire, validated for the setting. Educational outcomes (dropout) of the children at aged 7/8 years (end of 2013/2014 academic year) were obtained from maternal report. At age 8/9 years (end of 2014/2015 academic year), educational outcomes (academic achievement, absenteeism and dropout) of the children were obtained from school records.

RESULTS

After adjusting for potential confounders, exposure to maternal CMD at 7/8 years was associated significantly with school dropout (OR 1.07; 95% CI 1.00 to 1.13, P=0.043) and absenteeism (incidence rate ratio 1.01; 95% CI 1.00 to 1.02 P=0.026) at the end of 2014/2015 academic year. There was no association between maternal CMD and child academic achievement.

CONCLUSION

Future studies are needed to evaluate whether interventions to improve maternal mental health can reduce child school absenteeism and dropout.

Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a cluster-randomised trial in rural Bangladesh

OBJECTIVE

To determine the impact of environmental nudges on handwashing behaviours among primary school children as compared to a high-intensity hygiene education intervention.

METHODS

In a cluster-randomised trial (CRT), we compared the rates of handwashing with soap (HWWS) after a toileting event among primary school students in rural Bangladesh. Eligible schools (government run, on-site sanitation and water, no hygiene interventions in last year, fewer than 450 students) were identified, and 20 schools were randomly selected and allocated without blinding to one of four interventions, five schools per group: simultaneous handwashing infrastructure and nudge construction, sequential infrastructure then nudge construction, simultaneous infrastructure and high-intensity hygiene education (HE) and sequential handwashing infrastructure and HE. The primary outcome, incidence of HWWS after a toileting event, was compared between the intervention groups at different data collection points with robust-Poisson regression analysis with generalised estimating equations, adjusting for school-level clustering of outcomes.

RESULTS

The nudge intervention and the HE intervention were found to be equally effective at sustained impact over 5 months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). When comparing intervention delivery timing, the simultaneous delivery of the HE intervention significantly outperformed the sequential HE delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17).

CONCLUSION

Our trial demonstrates sustained improved handwashing behaviour 5 months after the nudge intervention. The nudge intervention's comparable performance to a high-intensity hygiene education intervention is encouraging.

Pilot of an Elementary School Cough Etiquette Intervention: Acceptability, Feasibility, and Potential for Sustainability

Schools convene many people together for a prolonged time, facilitating spread of respiratory pathogens and amplifying epidemics. Crowded Bangladeshi schools lack the infrastructure to support optimal cough etiquette behaviors. We collected formative data on current practices from four elementary schools, and developed and piloted a low-cost cough etiquette intervention, promoting coughing and sneezing into upper sleeves at four additional schools. We trained teachers to lead behavior change sessions during regular hygiene classes for 4 weeks. We evaluated intervention acceptability, feasibility, and potential for sustainability at 1 month and at 14 months after the intervention commenced. At baseline, among 63 observed students, 58 (92%) coughed/sneezed into open air, five (8%) covered coughs/sneezes with their hands, which were not subsequently washed with soap and water as they judged this infeasible. After 4 weeks, among 70 observed students, 27 (39%) coughed/sneezed into upper sleeves, 33 (47%) into open air, and 10 (12%) covered with hands. After 14 months, among 230 observed students, 13 (6%) used upper sleeves, 154 (67%) coughed/sneezed into open air, and 59 (26%) covered with hands. Students reported that coughing/sneezing into upper sleeves was simple and protected them and their classmates from germs. This school-based intervention was acceptable and feasible, and resulted in short-term reductions in coughing/sneezing into open air, but these habits of comparatively new behavior were not sustained as teachers ceased behavior change session delivery. Strategies to support longer-term adoption of habits should be considered.

Comparison of boiling and chlorination on the quality of stored drinking water and childhood diarrhoea in Indonesian households

We compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children 1000 MPN/100 ml (RR 1·86, 95% CI 1·09-3·19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children <5 years than water treatment by boiling, Air RahMat use remained low.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe

BACKGROUND

This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change.

METHODS

Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies.

RESULTS

The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme.

CONCLUSIONS

The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.

Optimizing Household Chlorination Marketing Strategies: A Randomized Controlled Trial on the Effect of Price and Promotion on Adoption in Haiti

Household water treatment can reduce diarrheal morbidity and mortality in developing countries, but adoption remains low and supply is often unreliable. To test effects of marketing strategies on consumers and suppliers, we randomized 1,798 households in rural Haiti and collected data on purchases of a household chlorination product for 4 months. Households received randomly selected prices ($0.11-$0.56 per chlorine bottle), and half received monthly visits from sales agents. Each $0.22 drop in price increased purchases by 0.10 bottles per household per month (P < 0.001). At the mean price, each 1% drop in price increased purchases by 0.45% (elasticity = 0.45). There is suggestive evidence that household visits by some sales agents increased purchases at mid-range prices; however, the additional revenue did not offset visit cost. Choosing the lowest price and conducting visits maximizes chlorine purchase, whereas slightly raising the retail price and not conducting visits maximizes cost recovery. For the equivalent cost, price discounts increase purchases 4.2 times as much as adding visits at the current retail price. In this context, price subsidies may be a more cost-effective use of resources than household visits, though all marketing strategies tested offer cost-effective ways to achieve incremental health impact. Decisions about pricing and promotion for health products in developing countries affect health impact, cost recovery, and cost-effectiveness, and tradeoffs between these goals should be made explicit in program design.

Educational intervention to reduce disease related to sub-optimal basic hygiene in Rwanda: initial evaluation and feasibility study

BACKGROUND

Despite a global reduction in morbidity related to sub-optimal water, sanitation and hygiene, the incidence of such diseases remains a significant problem in sub-Saharan Africa. This study aimed to initially assess the potential effectiveness (primarily in terms of impact on morbidity) of a simple educational intervention delivered in Rwanda. Additionally, we sought to explore feasibility relating to the practicality of evaluating and implementing this type of intervention in a low- and middle-income country.

METHODS

Two districts in Northern Province were purposively selected; one was randomly allocated to receive the intervention, with the other acting as control. The intervention was based on an interactive DVD about basic hygiene. Baseline and follow-up data for incident cases of relevant morbidities were collected from health centre records. Changes were compared between the two districts using descriptive statistics and chi-squared tests. Qualitative data were obtained through observations, discussions and feedback and were analysed thematically.

RESULTS

Cases of infection with intestinal worms and parasites were frequently recorded in both districts. For these morbidities, there was a 39% decrease in cases between baseline and follow-up in the intervention district (4995 reduced to 3069), compared to 13% (5002 reduced to 4356) in the control district (p < 0.001). Numbers of cases recorded as diarrhoea or dysentery, and changes between baseline and follow-up, were much lower (intervention district 1274 cases reduced to 1171; control district 1949 reduced to 1944). Qualitative data indicated a high level of acceptability for the intervention and also feasibility relating to the practicality of evaluation and implementation, whilst also highlighting problems encountered and possible solutions, in particular, the potential advantages of training local personnel to deliver this type of intervention.

CONCLUSIONS

This small-scale study has a number of acknowledged limitations which would need to be addressed in a larger study in order to confidently confirm the effectiveness of the intervention. It nevertheless provides evidence suggesting that the educational intervention is promising in terms of a potential impact on health and feasible to deliver and evaluate. These findings indicate that further evaluation and possibly early implementation are warranted.

TRIAL REGISTRATION

Research Registry, researchregistry2180.

Evaluation of Student Handwashing Practices During a School-Based Hygiene Program in Rural Western Kenya, 2007

Unsafe drinking water and inadequate handwashing facilities in primary schools increase the risk of absenteeism due to diarrhea and respiratory infections. To mitigate these risks, we provided 28 schools in rural Western Kenya with handwashing and drinking water stations (containers with lids and taps on metal stands), bleach for water treatment, soap for handwashing, and educational materials. We observed the use of the water stations and assessed teachers' attitudes toward the intervention. Of 151 total handwashing stations, 69 (59%) were observed to have soap and water and treated drinking water 4 months after implementation; observations of pupils showed an increase in handwashing behavior in water stations located < 10 m, as compared with those >10 m, from latrines ( p < .02). In focus groups, teachers reported improved cleanliness and decreased illness in pupils. Teacher training and installation of water stations resulted in observed improvements in pupils' hygiene, particularly when water stations were located <10 m from latrines.

Children as agents of change in combatting antibiotic resistance

Antibiotic resistance is a worldwide problem and changes are needed in the way antibiotics are used. The value of engaging children as key contributors in health care campaigns to increase the appropriate use of antibiotics has not been fully recognized. Little is known about how to design educational materials for children in order to enable them to be agents of change in their communities. Science education needs to improve the way it engages children so as to give them the tools needed to make responsible decisions on antibiotic use.

Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use

AbstractReducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.

Improving water, sanitation, and hygiene in schools in Indonesia: A cross-sectional assessment on sustaining infrastructural and behavioral interventions

Water, sanitation, and hygiene (WASH) in schools are important for child health, development, and educational performance; yet coverage in Indonesian schools remains low. To address this deficiency, UNICEF and partners conducted a WASH intervention in 450 schools across three provinces in Indonesia. A survey evaluating the sustainability of infrastructure and behavioral interventions in comparison to control districts was conducted one year after completion of the intervention. The survey data were also compared with national government data to assess the suitability of government data to report progress on the Sustainable Development Goals (SDGs). Logistic regression was used to explore associations between WASH conditions and behaviors. Intervention schools were more likely to have handwashing stations with soap and water. In multivariable analyses, schools with a toilet operation and maintenance fund were more likely to have functional toilets. Students who learn hygiene skills from their teachers were less likely to defecate openly, more likely to share hygiene knowledge with their parents, and more likely to wash their hands. Survey data were comparable with government data, suggesting that Indonesian government monitoring may be a reliable source of data to measure progress on the SDGs. This research generates important policy and practice findings for scaling up and sustaining WASH in schools and may help improve WASH in schools programs in other low-resource contexts.

Participatory science and innovation for improved sanitation and hygiene: process and outcome evaluation of project SHINE, a school-based intervention in Rural Tanzania

Background

Diarrheal disease is a major cause of mortality and morbidity in low and middle income countries with children being disproportionately affected. Project SHINE (Sanitation & Hygiene INnovation in Education) is a grassroots participatory science education and social entrepreneurship model to engage youth and the wider community in the development of sustainable strategies to improve sanitation and hygiene.

Methods

Based in rural and remote Tanzania, this pilot study engaged pastoralist high-school students and communities in the development and evaluation of culturally and contextually relevant strategies to improve sanitation and hygiene. Using a train-the-trainer approach, key activities included teacher workshops, school-based lessons, extra-curricular activities, community events and a One Health sanitation science fair which showcased projects related to water, sanitation and hygiene in relation to human and animal health. The process and outcome of the study were evaluated through qualitative interviews and focus group discussions with diverse project participants, as well as pre- and post- questionnaires completed by students on knowledge, attitudes and practices concerning sanitation and hygiene.

Results

The questionnaire results at baseline and follow-up showed statistically significant improvements on key measures including a decrease in unhygienic behaviors, an increase in the perceived importance of handwashing and intention to use the toilet, and increased communication in the social network about the importance of clean water and improved sanitation and hygiene practices, however there were no significant changes in sanitation related knowledge. Qualitative data highlighted strong leadership emerging from youth and enthusiasm from teachers and students concerning the overall approach in the project, including the use of participatory methods. There was a high degree of community engagement with hundreds of community members participating in school-based events. Sanitation science fair projects addressed a range of pastoralist questions and concerns regarding the relationship between water, sanitation and hygiene. Several projects, such as making soap from local materials, demonstrate potential as a sustainable strategy to improve health and livelihoods in the long-term.

Conclusions

The Project SHINE model shows promise as an innovative capacity building approach and as an engagement and empowerment strategy for youth and communities to develop locally sustainable strategies to improve sanitation and hygiene.

Evaluating four measures of water quality in clay pots and plastic safe storage containers in Kenya

Household water treatment with chlorine can improve microbiological quality and reduce diarrhea. Chlorination is typically assessed using free chlorine residual (FCR), with a lower acceptable limit of 0.2 mg/L, however, accurate measurement of FCR is challenging with turbid water. To compare potential measures of adherence to treatment and water quality, we chlorinated recently-collected water in rural Kenyan households and measured total chlorine residual (TCR), FCR, oxidation reduction potential (ORP), and E. coli concentration over 72 h in clay and plastic containers. Results showed that 1) ORP served as a useful proxy for chlorination in plastic containers up to 24 h; 2) most stored water samples disinfected by chlorination remained significantly less contaminated than source water for up to 72 h, even in the absence of FCR; 3) TCR may be a useful proxy indicator of microbiologic water quality because it confirms previous chlorination and is associated with a lower risk of E. coli contamination compared to untreated source water; and 4) chlorination is more effective in plastic than clay containers presumably because of lower chlorine demand in plastic.

The Impact of a School-Based Water, Sanitation, and Hygiene Program on Absenteeism, Diarrhea, and Respiratory Infection: A Matched-Control Trial in Mali

We conducted a matched-control trial in Mali to assess the effectiveness of a comprehensive school-based water, sanitation, and hygiene (WASH) intervention on pupil absence, diarrhea, and respiratory infections. After completion of the intervention, data were collected from 100 beneficiary schools and 100 matched comparison schools in 5-6 sessions over a 14-month period. Data collection included roll calls to assess absenteeism and interviews with a subset of pupils to assess recent absence and disease symptoms. The odds of pupils being absent at roll call were 23% higher in beneficiary schools than in comparison schools (odds ratio [OR]: 1.23, 95% confidence interval [CI]: 1.06, 1.42). The odds of pupils reporting being absent due to diarrhea (OR: 0.73, 95% CI: 0.56, 0.94) or having had diarrhea (OR: 0.71, 95% CI: 0.60, 0.85) or respiratory infection symptoms (OR: 0.75, 95% CI: 0.65, 0.86) in the past week were lower in beneficiary schools compared with comparison schools. We found that a school-based WASH intervention can have a positive effect on reducing rates of illness, as well as absence due to diarrhea. However, we did not find evidence that these health impacts led to a reduction in overall absence. Higher absence rates are less likely attributable to the intervention than the result of an imbalance in unobserved confounders between study groups.

Effects of an awareness raising campaign on intention and behavioural determinants for handwashing

This article assesses the effectiveness of The Great WASH Yatra handwashing awareness raising campaign in India on changing visitors' intention to wash hands with soap after using the toilet and the underlying behavioural determinants. Interviews based on the RANAS (Risk, Attitudes, Norms, Abilities, Self-regulation) model of behaviour change were conducted with 687 visitors before and after their visit to the campaign. Data showed that a campaign visit had little effect on the intention to wash hands with soap, even when comparing visitors who had actively participated in handwashing games with those who had not. After a campaign visit, knowledge about the benefits of washing hands had increased by almost half a standard deviation. A multiple linear regression analysis revealed that when considering all behavioural determinants change scores simultaneously, they were able to explain 57% of the variance in the intention change score. These findings suggest that substantively changing behaviour requires more than improving knowledge and emphasizing the importance of washing hands. Identifying the crucial behavioural determinants for handwashing may be an important first step in planning effective large-scale promotion programmes.

Quality of Kelantan drinking water and knowledge, attitude and practice among the population of Pasir Mas, Malaysia

OBJECTIVES

Information about the quality of drinking water, together with analysis of knowledge, attitude and practice (KAP) analysis and health risk assessment (HRA) remain limited. The aims of this study were: (1) to ascertain the level of KAP regarding heavy metal contamination of drinking water in Pasir Mas; (2) to determine the concentration of heavy metals (Al, Cr, Cu, Fe, Ni, Pb, Zn and Cd) in drinking water in Pasir Mas; and (3) to estimate the health risks (non-carcinogenic and carcinogenic) caused by heavy metal exposure through drinking water using hazard quotient and lifetime cancer risk.

METHODS

Information on KAP was collected using a standardized questionnaire. Heavy metal analysis of drinking water samples was performed using graphite furnace atomic absorption spectrophotometry.

RESULTS

The population of Pasir Mas has good knowledge (80%), a less positive attitude (93%) and good practice (81%) towards heavy metal contamination of drinking water. The concentrations of heavy metals analysed in this study were found to be below the permissible limits for drinking water set by the Malaysian Ministry of Health and the World Health Organization. The HRA showed no potential non-carcinogenic and carcinogenic risks from the intake of heavy metal through drinking water.

CONCLUSION

By investigating the quality of drinking water, KAP and HRA, the results of this study will provide authorities with the knowledge and resources to improve the management of drinking water quality in the future.

Water, sanitation, and hygiene in schools in low socio-economic regions in Nicaragua: a cross-sectional survey

Water, sanitation, and hygiene (WaSH) in schools contributes to better health and educational outcomes among school-aged children. In 2012, UNICEF Nicaragua and partners conducted a cross-sectional survey of WaSH in 526 schools in 12 low socio-economic status municipalities in Nicaragua. The survey gathered information on: school characteristics; teacher and community participation; water and sanitation infrastructure; and hygiene education and habits. Survey results were analyzed for associations between variables. WaSH coverage was significantly higher in urban than rural areas. Presence of drinking water infrastructure (43%) was lower than sanitation infrastructure (64%). Eighty-one percent of schools had no hand washing stations and 74% of schools lacked soap. Sanitation facilities were not in use at 28% of schools with sanitation infrastructure and 26% of schools with water infrastructure had non-functional systems. Only 8% of schools had budgets to purchase toilet-cleaning supplies and 75% obtained supplies from students’ families. This study generates transferable WaSH sector learnings and new insights from monitoring data. Results can be used by donors, service providers, and policy makers to better target resources in Nicaraguan schools.

Teacher perspectives on implementing and sustaining a handwashing promotion intervention in Western Kenyan primary schools

School-based handwashing programs are challenging to establish and sustain, especially in low-resource settings. This qualitative study described teacher perspectives associated with implementing and sustaining a handwashing program in primary schools participating in the Nyando Integrated Child Health and Education (NICHE) project. Structured key informant interviews were conducted with teachers. Prevalent concepts and themes were grouped into themes and topic areas using an iterative, open coding approach. Forty-one teacher respondents reported favorable expectations and benefits of handwashing programs. The importance of available resources (e.g., reliable water) was cited as a primary concern. Other challenges included time and personal or institutional financial commitment necessary to ensure program sustainability. Handwashing programs in low-income, rural schools, where infrastructure is lacking and "student ambassadors" extend the intervention to the surrounding community, hold great promise to improve community health. Teachers must have adequate support and resources to implement and sustain the programs.

Assessing the impact of a school-based latrine cleaning and handwashing program on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial

OBJECTIVES

Improving school water, sanitation and hygiene (WASH) conditions reduces pupil absence and illness. However, these benefits may depend on the conditions of the latrines and availability of consumables. We sought to determine whether a low-cost, policy-relevant, environmental-level latrine cleaning intervention could improve latrine cleanliness, increase its use and reduce absenteeism.

METHODS

In a three-arm, cluster-randomized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project. Latrine conditions and use were also assessed using structured observation. Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls, as did handwashing with soap. We found no difference in latrine use and absence across arms.

CONCLUSIONS

The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received. Improving latrine conditions is important for the dignity and well-being of pupils, and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly.