A cluster-randomized trial assessing the impact of school water, sanitation, and hygiene improvements on pupil enrollment and gender parity in enrollment

Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi

BACKGROUND

Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi.

METHODS

Rural primary schools (n = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) (n = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls (n = 100, 11-19 years; grades 5-8), teachers, mother groups, and community leaders from the selected schools.

RESULTS

All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines - VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction (p < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs.

CONCLUSION

The MHM project implementation improved adolescent girls' education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

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.

Policies and interventions to remove gender-related barriers to girls' school participation and learning in low- and middle-income countries: A systematic review of the evidence

BACKGROUND

Gender disparities in education continue to undermine girls' opportunities, despite enormous strides in recent years to improve primary enrolment and attainment for girls in low- and middle-income countries (LMICs). At the regional, country and subnational levels gender gaps remain, with girls in many settings less likely to complete primary school, less likely to complete secondary, and often less likely to be literate than boys. The academic and policy literatures on the topic of gender-related barriers to girls' education are both extensive. However, there remain gaps in knowledge regarding which interventions are most likely to work in contexts with different combinations of barriers.

OBJECTIVES

This systematic review identified and assessed the strength of the evidence of interventions and exposures addressing gender-related barriers to schooling for girls in LMICs.

SEARCH METHODS

The AEA RCT Registry, Africa Bibliography, African Education Research Database, African Journals Online, DEC USAID, Dissertation Abstracts, EconLit, ELDIS, Evidence Hub, Global Index Medicus, IDEAS-Repec, Intl Clinical Trials Registry, NBER, OpenGrey, Open Knowledge Repository, POPLINE, PsychINFO, PubMed, Research for Development Outputs, ScienceDirect, Sociological Abstracts, Web of Science, as well as relevant organization websites were searched electronically in March and April of 2019. Further searches were conducted through review of bibliographies as well as through inquiries to authors of included studies, relevant researchers and relevant organizations, and completed in March 2020.

SELECTION CRITERIA

We included randomized controlled trials as well as quasi-experimental studies that used quantitative models that attempted to control for endogeneity. Manuscripts could be either published, peer-reviewed articles or grey literature such as working papers, reports and dissertations. Studies must have been published on or after 2000, employed an intervention or exposure that attempted to address a gender-related barrier to schooling, analyzed the effects of the intervention/exposure on at least one of our primary outcomes of interest, and utilized data from LMICs to be included.

DATA COLLECTION AND ANALYSIS

A team of reviewers was grouped into pairs to independently screen articles for relevance, extract data and assess risk of bias for each included study. A third reviewer assisted in resolving any disputes. Risk of bias was assessed either through the RoB 2 tool for experimental studies or the ROBINS-I tool for quasi-experimental studies. Due to the heterogeneity of study characteristics and reported outcome measures between studies, we applied the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach adapted for situations where a meta-analysis is not possible to synthesize the research.

RESULTS

Interventions rated as effective exist for three gender-related barriers: inability to afford tuition and fees, lack of adequate food, and insufficient academic support. Promising interventions exist for three gender-related barriers: inadequate school access, inability to afford school materials, and lack of water and sanitation. More research is needed for the remaining 12 gender-related barriers: lack of support for girls' education, child marriage and adolescent pregnancy, lack of information on returns to education/alternative roles for women, school-related gender-based violence (SRGBV), lack of safe spaces and social connections, inadequate sports programs for girls, inadequate health and childcare services, inadequate life skills, inadequate menstrual hygiene management (MHM), poor policy/legal environment, lack of teaching materials and supplies, and gender-insensitive school environment. We find substantial gaps in the evidence. Several gender-related barriers to girls' schooling are under-examined. For nine of these barriers we found fewer than 10 relevant evaluations, and for five of the barriers-child marriage and adolescent pregnancy, SRGBV, inadequate sports programs for girls, inadequate health and childcare services, and inadequate MHM-we found fewer than five relevant evaluations; thus, more research is needed to understand the most effective interventions to address many of those barriers. Also, nearly half of programs evaluated in the included studies were multi-component, and most evaluations were not designed to tease out the effects of individual components. As a result, even when interventions were effective overall, it is often difficult to identify how much, if any, of the impact is attributable to a given program component. The combination of components varies between studies, with few comparable interventions, further limiting our ability to identify packages of interventions that work well. Finally, the context-specific nature of these barriers-whether a barrier exists in a setting and how it manifests and operates-means that a program that is effective in one setting may not be effective in another.

AUTHORS' CONCLUSIONS

While some effective and promising approaches exist to address gender-related barriers to education for girls, evidence gaps exist on more than half of our hypothesized gender-related barriers to education, including lack of support for girls' education, SRGBV, lack of safe spaces and social connections, inadequate life skills, and inadequate MHM, among others. In some cases, despite numerous studies examining interventions addressing a specific barrier, studies either did not disaggregate results by sex, or they were not designed to isolate the effects of each intervention component. Differences in context and in implementation, such as the number of program components, curricula content, and duration of interventions, also make it difficult to compare interventions to one another. Finally, few studies looked at pathways between interventions and education outcomes, so the reasons for differences in outcomes largely remain unclear.

Drinking water, sanitation, and hygiene (WASH) situation in primary schools of Pakistan: the impact of WASH-related interventions and policy on children school performance

The United Nation's Sustainable Development Goals include the target of ensuring access to water and sanitation and hygiene (WASH) for all; however, very few studies have assessed comprehensive school WASH service in Pakistan. The purpose of this study was to identify WASH services in primary schools of Pakistan, and to assess how recent WASH interventions and policies are associated with the school's academic performance. A representative cross-sectional study was conducted in primary schools in the Sindh province of Pakistan. Structured observations and interviews were done to ascertain the schools' WASH conditions. The primary exposures of interest were the implementation of previous WASH interventions and National WASH policy in the school and the WASH coverage. Outcomes of interest included WASH conditions and school performance. The structural equation modeling (SEM) using a bootstrap resampling procedure was employed to characterize how WASH exposures were associated with WASH conditions and school performance. Data were collected from 425 schools. The Basic WASH facilities coverage in the primary schools of Sindh remains overall low according to WHO WASH service ladder criteria. Also, inconsistency in all three inclusive domains of WASH (availability, accessibility, and functionality) facilities were found. The school performance was significantly associated (P<0.001) with the presence of WASH interventions and/or WASH policy, while WASH policy and/or recent WASH intervention at the school were not associated with overall water quality. Our assessment unveiled several WASH gaps that exist, including high heavy metal and fecal contamination. Adoption of national WASH policy and financing of evidence-based WASH interventions are recommended in primary schools to improve educational outcomes.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

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.

Diverse Health, Gender and Economic Impacts from Domestic Transport of Water and Solid Fuel: A Systematic Review

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda

Contaminated drinking water causes morbidity and mortality worldwide, especially in low- and middle-income countries. Drinking water quality has been studied extensively in household settings, but little research is available on drinking water quality in schools. School settings are of particular importance, because children are more susceptible than adults to a variety of diseases from contaminated drinking water. Many school water, sanitation and hygiene (WaSH) interventions have been studied for their efficacy to reduce diarrheal disease incidence, but few have evaluated drinking water quality, which reflects an important exposure pathway between WaSH services and health outcomes. Using school surveys developed from internationally established WaSH indicators and field microbiological water quality tests, we studied 374 rural schools in Mozambique and Uganda to understand the association between specific WaSH services and drinking water microbiological contamination, specifically testing most probable number (MPN) of Escherichia coli, an indicator of fecal contamination, per 100 mL. In Mozambique and Uganda, 71% and 83% respectively of rural schools had low risk drinking water quality (<1 E. coli/100 mL); thirteen percent and seven percent had very high-risk water quality (≥100 E. coli/100 mL). When accounting for all WaSH services studied, schools that used an improved-type water source had 0.22 times less E. coli in stored drinking water in Mozambique (95% CI: 0.07, 0.65) and 0.12 times less E. coli in Uganda (95% CI: 0.02, 0.80). In Mozambique, use of a water source within 30 minutes for travel and collection and the presence of water and soap/ash for handwashing were also significantly associated with less E. coli in drinking water. The findings of this study provide public health practitioners with implementable WaSH services to improve school drinking water quality, which has implications for the health, learning environment, and cognitive development of school children in rural Mozambique and Uganda.

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial

Objectives

To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children.

Methods

In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children’s independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children’s independent toothbrushing behaviour at home.

Results

Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857).

Conclusions

Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children’s uptake of independent hygiene behaviours.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01514-z) contains supplementary material, which is available to authorized users.

Water risk perceptions across the life-course of women in Kenya

Inadequate access to water, sanitation and hygiene (WaSH) exposes many vulnerable populations, especially women and girls, to preventable diseases around the world. This paper reports findings from a photovoice project that explored water-related risk perceptions and health outcomes among women in Nyanchwa, Kenya. Thirteen women in four age categories were recruited for this study in July 2016 using the 'snowball' technique. From the results, inadequate access to WaSH was associated with increased water collection burden on women and children; environmental pollution; poor educational outcomes; loss of time due to water collection and poor sanitation infrastructure. Some barriers to change identified include financial barriers and inadequate government support. The identified risks and barriers are important considerations for the design, evaluation and mainstreaming of WaSH programs in resource constrained settings.

The Sustainability and Scalability of Private Sector Sanitation Delivery in Urban Informal Settlement Schools: A Mixed Methods Follow Up of a Randomized Trial in Nairobi, Kenya

There are considerable challenges to achieving the Sustainable Development Goals’ target of universal access to basic sanitation in schools. Schools require safe, clean, and sex-segregated facilities for a large number of students. Robust and affordable solutions are needed to address the economic, spatial, social, institutional, and political factors which contribute to poor sanitary conditions in informal settlements. In 2015, we undertook a randomized controlled trial to assess the feasibility of private sector sanitation delivery (PSSD) in 20 primary schools, in informal settlements of Nairobi, Kenya. Our preliminary evaluation after one year of service delivery suggested that PSSD of urine-diverting dry latrines with routine waste collection and maintenance provided a feasible, lower-cost alternative to the government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. We conducted a mixed-methods follow-up study to assess sanitation delivery over 3–4 years and investigate prevailing drivers and barriers that may influence the scalability of PSSD. The conditions of newly constructed and rehabilitated GSD facilities diminished quickly, reverting to the conditions of existing facilities, indicating lower sustainability compared to sanitation delivered from the private sector. Barriers in financial aspects related to the ongoing implementation of PSSD emerged, particularly among public schools, and few were able to pay for continued service. Our study demonstrates that the engagement of the private sector may lead to improvements in affordable, safely managed sanitation for schools and their students. Yet, to reach a sustained scale, additional guidance is needed on how to develop these partnerships, streamline procurement and contracting processes, and incorporate appropriate financing mechanisms.

The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial

Background

Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level.

Methods

In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level.

Results

20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality – between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035).

Conclusion

Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure.

Trial registration

ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.

Having a toilet is not enough: the limitations in fulfilling the human rights to water and sanitation in a municipal school in Bahia, Brazil

Background

This article addresses the enjoyment of the human rights to water and sanitation (HRTWS), in particular access to toilets, in a public school in Bahia, Brazil.

Methods

Participant observation of the school’s routine, focus groups with students in grades 8 and 9 of primary school (13 to 17 years old) and individual, semi-structured, interviews with members of school staff were applied, exploring access to water and sanitation by adolescent girls and boys.

Results

Students and school staff reported that the amount of toilets was insufficient and that their conditions were often inadequate because they were plugged or dirty. The impact on girls is greater as toilets do not offer a clean and healthy environment for menstrual hygiene management. Several elements of the normative content of the HRTWS, especially accessibility, acceptability, quality, safety and dignity, were largely not fulfilled. The study identified that, to comply with the HRTWS, it is necessary to go beyond infrastructure, as the lack of maintenance; cultural elements and student participation hinder the usage of sanitary facilities. Since schools can be privileged spaces to train critical and reflective citizens and to foster autonomy and emancipation, education oriented by human rights and citizenship is an opportunity for a more equitable society. By increasing access to social, economic and cultural rights in all phases and aspects of life, including when children and adolescents are in a school environment, people are able to enjoy better living conditions and a higher standard of health.

Conclusions

The study raised the importance of considering each community’s sociocultural aspects in analyzing access to sanitary facilities in schools, which are spaces where citizens’ rights should be exercised and fulfilled.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6469-y) contains supplementary material, which is available to authorized users.

Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls

Introduction

While in school, girls require an environment that is supportive of menstrual hygiene management (MHM) in order to ensure regular school attendance and participation. Little is known about schoolgirls access to and practice of MHM in rural Zambia. This study explores girls’ experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls.

Methods

In July and August 2015, we conducted this qualitative exploratory study in six rural schools of Mumbwa and Rufunsa districts of Zambia. Twelve in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among girls ages 14–18 who had begun menstruating. Two FGDs with boys ages 14–18 and 25 key informant interviews were also conducted with teachers, female guardians and traditional leaders to provide the context within which schoolgirls practice MHM.

Results

Most girls reported learning about menstruation only at menarche and did not know the physiological basis of menstruation. They reported MHM-related challenges, including: use of non-absorbent and uncomfortable menstrual cloth and inadequate provision of sanitary materials, water, hygiene and sanitation facilities (WASH) in schools. In particular, toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls’ school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. Boys said they could tell when girls were menstruating by the smell and their behaviour, for instance, moving less and isolating themselves from their peers. Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls.

Conclusion

When menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6360-2) contains supplementary material, which is available to authorized users.

The impact of school water, sanitation, and hygiene improvements on infectious disease using serum antibody detection

Background

Evidence from recent studies assessing the impact of school water, sanitation and hygiene (WASH) interventions on child health has been mixed. Self-reports of disease are subject to bias, and few WASH impact evaluations employ objective health measures to assess reductions in disease and exposure to pathogens. We utilized antibody responses from dried blood spots (DBS) to measure the impact of a school WASH intervention on infectious disease among pupils in Mali.

Methodology/Principal findings

We randomly selected 21 beneficiary primary schools and their 21 matched comparison schools participating in a matched-control trial of a comprehensive school-based WASH intervention in Mali. DBS were collected from 20 randomly selected pupils in each school (n = 807). We analyzed eluted IgG from the DBS using a Luminex multiplex bead assay to 28 antigens from 17 different pathogens. Factor analysis identified three distinct latent variables representing vector-transmitted disease (driven primarily by dengue), food/water-transmitted enteric disease (driven primarily by Escherichia coli and Vibrio cholerae), and person-to-person transmitted enteric disease (driven primarily by norovirus). Data were analyzed using a linear latent variable model. Antibody evidence of food/water-transmitted enteric disease (change in latent variable mean (β) = -0.24; 95% CI: -0.53, -0.13) and person-to-person transmitted enteric disease (β = -0.17; 95% CI: -0.42, -0.04) was lower among pupils attending beneficiary schools. There was no difference in antibody evidence of vector-transmitted disease (β = 0.11; 95% CI: -0.05, 0.33).

Conclusions/Significance

Evidence of enteric disease was lower among pupils attending schools benefitting from school WASH improvements than students attending comparison schools. These findings support results from the parent study, which also found reduced incidence of self-reported diarrhea among pupils of beneficiary schools. DBS collection was feasible in this resource-poor field setting and provided objective evidence of disease at a low cost per antigen analyzed, making it an effective measurement tool for the WASH field.

Trial registration

The trial was registered at ClinicalTrials.gov (NCT01787058)

Water, sanitation, and hygiene (WASH) in schools is promoted as an intervention to improve child health in low-resource settings. However, evidence of the impact of school WASH interventions on child health is mixed. One reason could be that most studies rely on self-reported disease symptoms, which are prone to bias. In order to objectively measure evidence of disease, we collected dried blood spots (DBS) from pupils attending schools participating in an impact evaluation of a comprehensive school WASH intervention in Mali, and analyzed the DBS for antibody responses to 28 antigens from 17 different pathogens. We found that evidence of enteric disease was lower among pupils attending beneficiary schools compared to pupils attending comparison schools. These results are consistent with those from the parent study, which also found reduced self-reported diarrhea among pupils attending beneficiary schools. Our results support WASH in schools as an effective intervention to improve child health. Further, DBS are a feasible measurement tool for the WASH field to provide objective evidence of disease.

Design, Intervention Fidelity, and Behavioral Outcomes of a School-Based Water, Sanitation, and Hygiene Cluster-Randomized Trial in Laos

Evidence of the impact of water, sanitation, and hygiene (WASH) in schools (WinS) interventions on pupil absence and health is mixed. Few WinS evaluations rigorously report on output and outcome measures that allow for comparisons of effectiveness between interventions to be made, or for an understanding of why programs succeed. The Water, Sanitation, and Hygiene for Health and Education in Laotian Primary Schools (WASH HELPS) study was a randomized controlled trial designed to measure the impact of the United Nations Children's Fund (UNICEF) Laos WinS project on child health and education. We also measured the sustainability of intervention outputs and outcomes, and analyzed the effectiveness of group hygiene activities on behavior change and habit formation. Here, we present the design and intermediate results from this study. We found the WinS project improved the WASH environment in intervention schools; 87.8% of schools received the intervention per design. School-level adherence to outputs was lower; on average, schools met 61.4% of adherence-related criteria. The WinS project produced positive changes in pupils' school WASH behaviors, specifically increasing toilet use and daily group handwashing. Daily group hygiene activities are effective strategies to improve school WASH behaviors, but a complementary strategy needs to be concurrently promoted for effective and sustained individual handwashing practice at critical times.

Estimating the Effect of School Water, Sanitation, and Hygiene Improvements on Pupil Health Outcomes

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We conducted a cluster-randomized water, sanitation, and hygiene trial in 185 schools in Nyanza province, Kenya. The trial, however, had imperfect school-level adherence at many schools. The primary goal of this study was to estimate the causal effects of school-level adherence to interventions on pupil diarrhea and soil-transmitted helminth infection.

Water, sanitation, and hygiene in schools: Status and implications of low coverage in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia

Adequate access to water, sanitation, and hygiene (WaSH) in schools impacts health, educational outcomes, and gender disparities. Little multi-country research has been published on WaSH in rural schools in Sub-Saharan Africa. In this multi-national cross-sectional WaSH study, we document WaSH access, continuity, quality, quantity, and reliability in 2270 schools that were randomly sampled in rural regions of six Sub-Saharan African countries: Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Data collection included: school WaSH surveys containing internationally established WaSH indicators, direct observation, and field- and laboratory-based microbiological water quality testing. We found 1% of rural schools in Ethiopia and Mozambique to 23% of rural schools in Rwanda had improved water sources on premises, improved sanitation, and water and soap for handwashing. Fewer than 23% of rural schools in the six countries studied met the World Health Organization's recommended student-to-latrine ratios for boys and for girls. Fewer than 20% were observed to have at least four of five recommended menstrual hygiene services (separate-sex latrines with doors and locks, water for use, waste bin). The low access to safe and adequate WaSH services in rural schools suggest opportunities for WaSH interventions that could have substantive impact on health, education, and gender disparities.

'Fit for school' - a school-based water, sanitation and hygiene programme to improve child health: Results from a longitudinal study in Cambodia, Indonesia and Lao PDR

BACKGROUND

The Fit for School (FIT) programme integrates school health and Water, Sanitation and Hygiene interventions, which are implemented by the Ministries of Education in four Southeast Asian countries. This paper describes the findings of a Health Outcome Study, which aimed to assess the two-year effect of the FIT programme on the parasitological, weight, and oral health status of children attending schools implementing the programme in Cambodia, Indonesia and Lao PDR.

METHODS

The study was a non-randomized clustered controlled trial with a follow-up period of two years. The intervention group consisted of children attending public elementary schools implementing the FIT programme, including daily group handwashing with soap and toothbrushing with fluoride toothpaste, biannual school-based deworming; as well as construction of group handwashing facilities. Control schools implemented the regular government health education curriculum and biannual deworming. Per school, a random selection of six to seven-year-old grade-one students was drawn. Data on parasitological infections, anthropometric measurements, dental caries, odontogenic infections and sociodemographic characteristics were collected at baseline and at follow-up (24 months later). Data were analysed using the χ²-test, Mann Whitney U-test and multilevel logistic and linear regression.

RESULTS

A total of 1847 children (mean age = 6.7 years, range 6.0-8.0 years) participated in the baseline survey. Of these, 1499 children were available for follow-up examination - 478, 486 and 535 children in Cambodia, Indonesia and Lao PDR, respectively. In all three countries, children in intervention schools had a lower increment in the number of decayed, missing and filled permanent teeth between baseline and follow-up, in comparison to children in controls schools. The preventive fraction was 24% at average. The prevalence of soil-transmitted helminth infection (which was unexpectedly low at baseline), the prevalence of thinness and the prevalence of odontogenic infections did not significantly differ between baseline and follow-up, nor between intervention and control schools.

CONCLUSIONS

The study found that the FIT programme significantly contributed to the prevention of dental caries in children. This study describes the challenges, learnings and, moreover, the importance of conducting real-life implementation research to evaluate health programmes to transform school settings into healthy learning environments for children. The study is retrospectively registered with the German Clinical Trials Register, University of Freiburg (Trial registration number: DRKS00004485, date of registration: 26th of February, 2013).

Water Quality, Sanitation, and Hygiene Conditions in Schools and Households in Dolakha and Ramechhap Districts, Nepal: Results from A Cross-Sectional Survey

This study assessed drinking water quality, sanitation, and hygiene (WASH) conditions among 708 schoolchildren and 562 households in Dolakha and Ramechhap districts of Nepal. Cross-sectional surveys were carried out in March and June 2015. A Delagua water quality testing kit was employed on 634 water samples obtained from 16 purposively selected schools, 40 community water sources, and 562 households to examine water quality. A flame atomic absorption spectrophotometer was used to test lead and arsenic content of the same samples. Additionally, a questionnaire survey was conducted to obtain WASH predictors. A total of 75% of school drinking water source samples and 76.9% point-of-use samples (water bottles) at schools, 39.5% water source samples in the community, and 27.4% point-of-use samples at household levels were contaminated with thermo-tolerant coliforms. The values of water samples for pH (6.8–7.6), free and total residual chlorine (0.1–0.5 mg/L), mean lead concentration (0.01 mg/L), and mean arsenic concentration (0.05 mg/L) were within national drinking water quality standards. The presence of domestic animals roaming inside schoolchildren’s homes was significantly associated with drinking water contamination (adjusted odds ratio: 1.64; 95% confidence interval: 1.08–2.50; p = 0.02). Our findings call for an improvement of WASH conditions at the unit of school, households, and communities.

The Role of Adherence on the Impact of a School-Based Water, Sanitation, and Hygiene Intervention in Mali

AbstractStudies assessing the impacts of school-based water, sanitation, and hygiene (WASH) interventions have revealed inconsistent improvements in pupils' health and educational outcomes. This may be in part due to suboptimal project fidelity or adherence. As part of a matched-control trial of a comprehensive school-based WASH project in Mali, we measured the degree to which schools met four prespecified WASH targets, comprised of 15 criteria, 0-3 years after program implementation. We compared achievement of the targets and criteria between beneficiary and matched control schools, and compared achievement within beneficiary schools at baseline and at follow-up visits. We assessed the "as-treated" associations between WASH target achievement and pupil diarrhea, respiratory symptoms, and absence. Between 44% and 81% of beneficiary schools achieved each target. Although adherence was inconsistent across schools, beneficiary schools, on average, met more WASH targets than matched control schools, and beneficiary schools also met more WASH targets at follow-up than at baseline. Very few of the targets were individually associated with health and absenteeism outcomes. Increasing achievement of multiple WASH targets together was associated with a lower odds of pupils having diarrhea (P trend < 0.01) and having respiratory symptoms (P trend < 0.01), but was not associated with roll-call absence (P trend = 0.14) or pupil-reported absence (P trend = 0.41). These results indicate that a comprehensive WASH intervention and a focus on increasing adherence may help maximize the health effects of school WASH programs, but that WASH alone might not be sufficient to decrease pupils' absenteeism.

The Life-Cycle Costs of School Water, Sanitation and Hygiene Access in Kenyan Primary Schools

Water, Sanitation and Hygiene (WASH) programs in schools can increase the health, dignity and comfort of students and teachers. Understanding the costs of WASH facilities and services in schools is one essential piece for policy makers to utilize when budgeting for schools and helping to make WASH programs more sustainable. In this study we collected data from NGO and government offices, local hardware shops and 89 rural primary schools across three Kenyan counties. Current expenditures on WASH, from school and external (NGO, government, parent) sources, averaged 1.83 USD per student per year. After reviewing current expenditures, estimated costs of operations and maintenance for bringing schools up to basic WASH standards, were calculated to be 3.03 USD per student per year. This includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was 18,916 USD per school, for a school of 400 students (4.92 USD per student, per year). These findings demonstrate the need for increases in allocations to schools in Kenya, and stricter guidance on how money should be spent on WASH inputs to enable all schools to provide basic WASH for all students.

Evaluation of water, sanitation and hygiene program outcomes shows knowledge-behavior gaps in Coast Province, Kenya

INTRODUCTION

Water related diseases constitute a significant proportion of the burden of disease in Kenya. Water, sanitation and hygiene (WASH) programs are in operation nation-wide to address these challenges. This study evaluated the impact of the Sombeza Water and Sanitation Improvement Program (SWASIP) in Coast Province, Kenya.

METHODS

This study is a cluster randomized, follow-up evaluation that compared baseline (2007) to follow-up (2013) indicators from 250 households. Twenty-five villages were selected with probability proportional to size sampling, and ten households were selected randomly from each village. Follow-up data were collected by in-person interviews using pre-tested questionnaires, and analyzed to compare indicators collected at baseline. Cross-sectional results from the follow-up data were also reported.

RESULTS

Statistically significant improvements from baseline were observed in the proportions of respondents with latrine access at home, who washed their hands after defecation, who treated their household drinking water and the average time to collect water in the dry season. However, this study also observed significant decreases in the proportion of respondents who washed their hands before preparing their food, or feeding their children, and after attending to a child who has defecated. The analysis also revealed a knowledge-behavior gap in WASH behaviors.

CONCLUSION

SWASIP contributed to improvements from baseline, but further progress still needs to be seen. The findings challenge the assumption that providing infrastructure and knowledge will result in behavior change. Further understanding of specific, non-knowledge predictors of WASH related behavior is needed.

School Water, Sanitation, and Hygiene, Soil-Transmitted Helminths, and Schistosomes: National Mapping in Ethiopia

Background

It is thought that improving water, sanitation, and hygiene (WASH) might reduce the transmission of schistosomes and soil-transmitted helminths, owing to their life cycles. However, few large-scale studies have yet assessed the real extent of associations between WASH and these parasites.

Methodology/Principal Findings

In the 2013–2014 Ethiopian national mapping of infections with these parasites, school WASH was assessed alongside infection intensity in children, mostly between 10 and 15 years of age. Scores were constructed reflecting exposure to schistosomes arising from water collection for schools, from freshwater sources, and the adequacy of school sanitation and hygiene facilities. Kendall’s τ_b was used to test the WASH scores against the school-level arithmetic mean intensity of infection with each parasite, in schools with at least one child positive for the parasite in question.

WASH and parasitology data were available for 1,645 schools. More frequent collection of water for schools, from open freshwater sources was associated with statistically significantly higher Schistosoma mansoni infection intensity (Kendall’s τ_b = 0.097, 95% confidence interval, CI: 0.011 to 0.18), better sanitation was associated with significantly lower Ascaris lumbricoides intensity (Kendall’s τ_b = -0.067, 95% CI: -0.11 to -0.023) and borderline significant lower hookworm intensity (Kendall’s τ_b = -0.039, 95% CI: -0.090 to 0.012, P = 0.067), and better hygiene was associated with significantly lower hookworm intensity (Kendall’s τ_b = -0.076, 95% CI: -0.13 to -0.020). However, no significant differences were observed when comparing sanitation and infection with S. mansoni or Trichuris trichiura, or hygiene and infection with A. lumbricoides or T. trichiura.

Conclusions/Significance

Improving school WASH may reduce transmission of these parasites. However, different forms of WASH appear to have different effects on infection with the various parasites, with our analysis finding the strongest associations between water and S. mansoni, sanitation and A. lumbricoides, and hygiene and hookworm.

Water, sanitation, and hygiene (WASH) are potentially important control measures for parasitic worms, but few large-scale and well-designed research studies have aimed to quantify the relationships between WASH and infections with these parasites, or demonstrated the practicality of integrating WASH assessments into large-scale worm mapping. Here we use data from 80,475 children in 1,645 schools visited during the 2013–2014 Ethiopian national mapping of schistosomiasis and soil-transmitted helminthiases, to compare school WASH conditions with the mean intensity of infection with these parasites, using Kendall’s τ_b, a statistic that assesses for correlation between two variables by comparing their rankings. More frequent collection of water for schools was associated with statistically significantly (P < 0.05) higher-intensity intestinal schistosomiasis infections, better sanitation significantly with lower roundworm burdens, and better hygiene with significantly lower hookworm burdens. No statistically significant associations (P > 0.05) were found for sanitation and intestinal schistosomiasis or whipworm infections, or hygiene and roundworm or whipworm infections, but better sanitation was associated with a borderline statistically significantly less hookworm infections (P = 0.067). The results suggest that WASH improvements might have different impacts on infection with the various parasites. These differences should be borne in mind when designing WASH interventions to reduce transmission of, and prevent infection with, these parasites.

Ascaris lumbricoides Infection Following School-Based Deworming in Western Kenya: Assessing the Role of Pupils' School and Home Water, Sanitation, and Hygiene Exposures

Water, sanitation, and hygiene (WaSH) technologies and behaviors can prevent infection by soil-transmitted helminth species independently, but may also interact in complex ways. However, these interactions are poorly understood. The purpose of this study was to characterize how school and home WaSH exposures were associated with Ascaris lumbricoides infection and to identify relevant interactions between separate WaSH technologies and behaviors. A study was conducted among 4,404 children attending 51 primary schools in western Kenya. We used multivariable mixed effects logistic regression to characterize how various WaSH exposures were associated with A. lumbricoides infection after annual school-based deworming. Few WaSH behaviors and technologies were independently associated with A. lumbricoides infection. However, by considering relevant interdependencies between variables, important associations were elucidated. The association between handwashing and A. lumbricoides depended largely upon the pupils' access to an improved water source. Among pupils who had access to improved water sources, A. lumbricoides prevalence was lower for those who handwashed both at school and home compared with neither place (odds ratio: 0.38, 95% confidence interval: 0.18–0.83; P = 0.01). This study contributes to a further understanding of the impact of WaSH on A. lumbricoides infection and shows the importance of accounting for interactions between WaSH technologies and behaviors.

A Time for Global Action: Addressing Girls' Menstrual Hygiene Management Needs in Schools

Marni Sommer and colleagues reflect on priorities needed to guide global, national, and local action to address girls' menstrual hygiene management needs in schools.

Baseline prevalence and intensity of schistosomiasis at sentinel sites in Madagascar: Informing a national control strategy

BACKGROUND

Schistosomiasis affects more than 800 million people, mostly in sub-Saharan Africa. A baseline sentinel site study was conducted in the Western half of Madagascar to determine the prevalence and intensity of schistosomiasis and soil-transmitted helminth (STH) infections prior to mass drug administration, and to explore the associations between infection and school attendance, and access to water, sanitation and hygiene (WASH) facilities.

METHODS

A three-stage, cluster-randomised cross-sectional study was conducted in 29 sentinel sites in October 2015. Twenty school attending and 4 non-attending children in each of the age groups from 7 to 10 years old were randomly selected at each site for detection of Schistosoma haematobium eggs in a single urine slide by filtration, and of S. mansoni, Ascaris lumbricoides, Trichuris trichiura and hookworm eggs in duplicate Kato-Katz slides from a single stool sample. School attendance was registered individually, and school-level access to WASH facilities was scored through pre-defined observed and reported factors. Logistic regression analysis was performed, adjusting for gender, age and study site. School-level WASH status was analysed using Spearman's rank correlation coefficient.

RESULTS

A total of 1,958 children were included. The prevalence of S. haematobium infection and heavy-intensity infection was 30.5% and 15.1%, respectively. The prevalence of S. mansoni infection and heavy-intensity infection was 5.0% and 0.9%, respectively. The prevalence of any STH infection was 4.7%. There was no significant difference in prevalence of infection or heavy-intensity infection of either schistosome species between attending and non-attending children, apart from heavy-intensity S. mansoni infection that was significantly more common in children who did not attend school regularly (aOR = 7.5 (95% CI = 1.1-49.5); p = 0.037). Only a minority of schools had adequate access to WASH facilities, and in this study, we found no significant association between school-level WASH status and schistosomiasis.

CONCLUSIONS

This study found an alarmingly high prevalence and intensity of schistosomiasis, and the results warrant urgent scale-up of the national NTD control programme that will need to include both non-attending and attending school-age children in order to reach WHO roadmap targets for the control of schistosomiasis by 2020.

Interrupting transmission of soil-transmitted helminths: a study protocol for cluster randomised trials evaluating alternative treatment strategies and delivery systems in Kenya

INTRODUCTION

In recent years, an unprecedented emphasis has been given to the control of neglected tropical diseases, including soil-transmitted helminths (STHs). The mainstay of STH control is school-based deworming (SBD), but mathematical modelling has shown that in all but very low transmission settings, SBD is unlikely to interrupt transmission, and that new treatment strategies are required. This study seeks to answer the question: is it possible to interrupt the transmission of STH, and, if so, what is the most cost-effective treatment strategy and delivery system to achieve this goal?

METHODS AND ANALYSIS

Two cluster randomised trials are being implemented in contrasting settings in Kenya. The interventions are annual mass anthelmintic treatment delivered to preschool- and school-aged children, as part of a national SBD programme, or to entire communities, delivered by community health workers. Allocation to study group is by cluster, using predefined units used in public health provision-termed community units (CUs). CUs are randomised to one of three groups: receiving either (1) annual SBD; (2) annual community-based deworming (CBD); or (3) biannual CBD. The primary outcome measure is the prevalence of hookworm infection, assessed by four cross-sectional surveys. Secondary outcomes are prevalence of Ascaris lumbricoides and Trichuris trichiura, intensity of species infections and treatment coverage. Costs and cost-effectiveness will be evaluated. Among a random subsample of participants, worm burden and proportion of unfertilised eggs will be assessed longitudinally. A nested process evaluation, using semistructured interviews, focus group discussions and a stakeholder analysis, will investigate the community acceptability, feasibility and scale-up of each delivery system.

ETHICS AND DISSEMINATION

Study protocols have been reviewed and approved by the ethics committees of the Kenya Medical Research Institute and National Ethics Review Committee, and London School of Hygiene and Tropical Medicine. The study has a dedicated web site.

TRIAL REGISTRATION NUMBER

NCT02397772.

Factors associated with pupil toilet use in kenyan primary schools

The purpose of this study was to quantify how school sanitation conditions are associated with pupils’ use of sanitation facilities. We conducted a longitudinal assessment in 60 primary schools in Nyanza Province, Kenya, using structured observations to measure facility conditions and pupils’ use at specific facilities. We used multivariable mixed regression models to characterize how pupil to toilet ratio was associated with toilet use at the school-level and also how facility conditions were associated with pupils’ use at specific facilities. We found a piecewise linear relationship between decreasing pupil to toilet ratio and increasing pupil toilet use (p < 0.01). Our data also revealed significant associations between toilet use and newer facility age (p < 0.01), facility type (p < 0.01), and the number of toilets in a facility (p < 0.01). We found some evidence suggesting facility dirtiness may deter girls from use (p = 0.06), but not boys (p = 0.98). Our study is the first to rigorously quantify many of these relationships, and provides insight into the complexity of factors affecting pupil toilet use patterns, potentially leading to a better allocation of resources for school sanitation, and to improved health and educational outcomes for children.

Impact of regular soap provision to primary schools on hand washing and E. coli hand contamination among pupils in Nyanza Province, Kenya: a cluster-randomized trial

We assessed whether supplying soap to primary schools on a regular basis increased pupil hand washing and decreased Escherichia coli hand contamination. Multiple rounds of structured observations of hand washing events after latrine use were conducted in 60 Kenyan schools, and hand rinse samples were collected one time in a subset of schools. The proportion of pupils observed practicing hand washing with soap (HWWS) events was significantly higher in schools that received a soap provision intervention (32%) and schools that received soap and latrine cleaning materials (38%) compared with controls (3%). Girls and boys had similar hand washing rates. There were non-significant reductions in E. coli contamination among intervention school pupils compared with controls. Removing the barrier of soap procurement can significantly increase availability of soap and hand washing among pupils; however, we discuss limitations in the enabling policy and institutional environment that may have prevented reaching desired levels of HWWS.