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

M. Common intestinal parasitic infections in an improved water access, sanitation, and hygiene profile setting in North Jakarta, Indonesia

Intestinal parasitic infections (IPIs), caused by helminths and/or protozoa, continue to be a significant public health concern in Indonesia. Water access, sanitation, and hygiene practices (WASH) are influential factors for IPIs, especially among children. The aim of this study was to investigate the association between WASH and IPIs among school-aged children. A cross-sectional study involving 338 school-age children in an urban slum area in North Jakarta, Indonesia, was conducted using stool specimens subjected to microscopic and real-time polymerase chain reaction (rt-PCR) examination. The children underwent a finger-prick blood test and anthropometric measurements to determine anemia and nutritional status. Parents whose children participated in stool and blood examinations were interviewed using a modified WASH questionnaire. Helminth infections were not found in this study, whereas the overall prevalence of intestinal protozoa parasitic infection (IPPI) was 18.3% and 52.4% by microscopy and rt-PCR, respectively. Blastocystis spp. was found to have the highest prevalence (microscopy: 12%; rt-PCR: 48.6%), followed by Giardia intestinalis (microscopy: 0.6%; rt-PCR: 6.7%), Cryptosporidium spp. (microscopy: 5.1%; rt-PCR: 1.6%), and Entamoeba histolytica/dispar (microscopy: 0.6%; rt-PCR: 3.2%). Additionally, Dientamoeba fragilis was detected by rt-PCR at 4.1%. Furthermore, the discrepancies between microscopy and rt-PCR were observed in 8.9% (n = 28) of the examined specimens. The majority of the respondents had a low-risk category of WASH profile. School children aged 5-10 years old (OR = 2.06; 95%CI = 1.27-3.33) and those who drank unprocessed cooking water (OR = 1.95; 95%CI = 1.07-3.57) were significantly associated with IPPI. The present study demonstrated that rt-PCR provides a better understanding of IPI epidemiology and has potential as a monitoring strategy for managing IPIs. Even though this population exhibits an adequate WASH profile and is not directly associated with IPIs, conducting a more in- depth observation of WASH facilities and practices is recommended to ensure a comprehensive assessment of the WASH profile. Additionally, engaging stakeholders in health promotion programs to ensure the sustainability of a good WASH profile and awareness of parasitic infections will be advantageous in achieving optimal urban health.

How does the citizens' choice of water use actions based on their empirical knowledge affect the water quality in a rural community of the Philippines?

This research assessed water quality, based on the purpose of water consumption, in households in the municipality of Barbaza, the Province of Antique, Philippines, according to the national water quality guidelines. The effects of the empirical/traditional water use actions taken by local people on the quality of the water they use were investigated through a descriptive study using water quality measurements. Most of the drinking water in the community did not meet the required standards of pH, total dissolved solids (TDS), or coliform. Tap water and well water samples generally met the pH and TDS standards. However, Escherichia coli (E. coli) and coliform were detected, and nitrogen pollution in well water was also confirmed. Local practices, such as using old clothes as filters for well pumps, increased the coliform concentration from 0-10 CFU/mL to too numerous to count (TNTC) levels of more than 100 CFU/mL. Storing well water in a bucket also affected both E. coli and coliform concentrations. Such empirical/traditional water use actions create a high risk of exposing local people to harmful microorganisms. This research integrated citizen science into the methodology for local water management, which could assist governors, practitioners, and citizens, particularly in Southeast Asia, where strong community relationships exist.

Effectiveness of a continuous handwashing education program with multiple activities at a Japanese kindergarten school

Formation of proper handwashing techniques and habits from childhood is important for disease prevention. However, there are few studies that comprehensively and longitudinally evaluate the effectiveness of handwashing education for kindergarteners. This study aims to evaluate the effectiveness of continuous handwashing education using multiple activities to improve handwashing practices and skills among first- to third-grade students at a kindergarten in central Japan. A quasi-experimental one group pre- and post-test design was used. The education program consisted of three activities: (i) a 1-day teaching session by a researcher in January 2021, (ii) a 1-month follow-up activity led by kindergarten teachers and (iii) a 1-month follow-up activity led by parents at home, both occurring from late January to late February 2021. The study used questionnaires and handwashing skill experiments to investigate the kindergarteners' handwashing practices and comprehensive handwashing skills (handwashing steps, handwashing time, rinsing time and areas of the hands left unwashed) before and after Activities 1, 2 and 3. Data were obtained from 56 kindergarteners (64.4%). Second and third graders showed a significant improvement in their handwashing practices after coughing or sneezing. With the exception of rinsing time, handwashing skills significantly improved in all grades after the 1-day teaching session. After 1-month follow-up activities, the number of areas left unwashed by first graders significantly decreased, and the score for handwashing steps significantly improved. This study indicated that continuous handwashing education is partially effective at improving and maintaining handwashing practices and skills, except for rinsing time, among kindergarteners of all grades.

Water and Sanitation Access for Children in Alabama

BACKGROUND AND OBJECTIVES

Safe drinking water and closed sanitation are fundamental to health and are assumed in the United States, however, gaps remain, disproportionately affecting marginalized communities. We sought to describe household sanitation access for children in rural Alabama and local health provider knowledge of sanitation related health concerns.

METHODS

Data were collected from self-administered surveys obtained from children enrolled in a larger cross-sectional study to determine soil transmitted helminthiasis prevalence in Alabama, from a survey of health providers from local federally qualified health centers and from a baseline knowledge check of Alabama health providers enrolled in an online sanitation health course.

RESULTS

Surveys completed on 771 children (approximately 10% of county pediatric population) revealed less than half lived in homes connected to centralized sewers; 12% reported "straight-pipes," a method of discharging untreated sewage to the ground outside the home, and 8% reported sewage contamination of their home property in the past year. Additionally, 15% of respondents were likely to use well water. The local health providers surveyed did not include routine screening for water and sanitation failures or associated infections. Regional healthcare providers have limited knowledge of soil transmitted helminthiasis.

CONCLUSIONS

A significant number of children from rural counties of Alabama with high rates of poverty reside in homes with water and sanitation challenges that predominantly affect African American families. This is an under-recognized health risk by local health providers, and its contribution to well-documented health disparities in this region is poorly understood.

Water, Sanitation, and Hygiene Infrastructure and Resources in Schools in Belize during the COVID-19 Pandemic, 2021-2023

Access to water, sanitation, and hygiene (WASH) resources in schools is critical for disease prevention and control, especially during public health emergencies. In Belize, systematic, national data on WASH in schools are needed to inform public health decisions and interventions. From December 2021 to January 2022, a national survey was sent electronically to government and government-aided primary and secondary schools in Belize (N = 308) to gather information on WASH services. From the survey, 12 pilot schools were selected based on the highest self-reported need for WASH resources to participate in additional evaluation and intervention, which included environmental nudges, supplemental supply provision, and hand hygiene education. To understand how the progression of the COVID-19 pandemic may have influenced hand hygiene, facility assessments to evaluate access to hand hygiene resources were conducted in person when most schools reopened for face-to-face learning during the pandemic (March 2022) and 15 months later (June 2023). Among the schools participating in the national survey (N = 221), 55% reported times when water was not available at the schools. Almost 9 in 10 schools (89%) had a functional handwashing station, and 47% reported always having soap for handwashing. Between baseline and follow-up at the 12 pilot schools, we observed decreases in the proportion of functional handwashing access points (-11%), functional handwashing access points accessible for individuals with disabilities (-17%) and small children (-29%), and functional alcohol-based hand rub dispensers (-13%). Despite the ongoing COVID-19 pandemic, we observed gaps in WASH resources in schools in Belize during the onsite assessments at the pilot schools. Schools should be encouraged and provided with WASH resources to maintain vigilance for disease control measures.

The Status of School Water, Sanitation, and Hygiene Services in Addis Ababa, Ethiopia: Progress Towards Achieving the SDG 6

Background

The provision of safe water, sanitation, and hygiene (WASH) facilities and services for schools is vital to students' health, development, and educational performance. However, school WASH coverage in developing countries remains low. This study aimed to assess the adequacy of WASH services in Addis Ababa, Ethiopia.

Methods

A school-based quantitative cross-sectional study was conducted from January to March 2020 in 98 schools. A multistage sampling technique was used to select schools included in the study. Data were collected using observational checklists and pretested interviewer-administered questionnaires. We entered the data into EPI Info version 7.2.2.6 and analyzed using SPSS 22.0. Logistic regression was used to examine the associated factors with school WASH services.

Results

The basic school water, sanitation, and hygiene services were found to be 65.3%, 31.6%, and 36.7%, respectively. The facility-to-student ratio was 1:48 for drinking water point, 1:59 for toilet stance, and 1:147 for handwashing point. The analysis of facilities access by sex revealed that the toilet to student ratio was 1:68 for females and 1:49 for males, whereas the handwashing point-to-student ratio was 1:179 for females and 1:114 for males, indicating disparities in facilities access by sex. The non-functionality rates for drinking water, toilets, and handwashing facilities were 22.5%, 8%, and 19.5%, respectively. School ownership was significantly associated with the availability of basic water services [COR = 4.6, 95% CI: 1.466-14.426] and basic sanitation services [COR = 15, 95% CI: 3.27-68.28]. Moreover, the results demonstrate training on WASH [COR = 5, 95% CI: 1.087-23.018] and teaching programs on WASH [COR = 0.21, 95% CI: 0.056-0.810] were significantly associated with basic hygiene services.

Conclusions

The provision of WASH facilities and services in schools was inadequate and not on track to meet the targets of SDG 6. Training, WASH education program, and stakeholder commitment and cooperation at all levels are required to achieve the goal.

Enhancing the effectiveness of infectious disease health education for children and adolescents in China: a national multicenter school-based trial

BACKGROUND

Infectious diseases pose a significant risk to the health and well-being of children and adolescents, and can even be life-threatening. Thus, our study aimed to explore the effectiveness of health education based on the social-ecological model in improving the knowledge of infectious diseases among this vulnerable population.

METHODS

This study was a school-based intervention conducted in seven Chinese provinces in 2013, involving a total of 26,591 children and adolescents in the intervention group and 24,327 in the control group. The intervention group received a comprehensive health intervention based on the social-ecological model (SEM) over six months, which included a supportive environment, health education on infectious diseases, guidance on self-monitoring infectious disease-related behaviors, and other measures. Data on infectious disease-related knowledge and other characteristics were collected through questionnaires. The main outcome measure will be the difference in the effectiveness of health education regarding infectious diseases in children and adolescents between baseline and post-intervention. A mixed-effects regression model was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) to assess the impact of infectious disease-related interventions on the participants.

RESULTS

We utilized a socioecological model as the foundation for a six-month health education program on infectious diseases targeting children and adolescents in the intervention group. At the individual and community levels, the correct rate of health behavior related to infectious diseases in the intervention group was higher than that in the control group (P < 0.05), the ORs (95% CI) were 0.94 (0.90-0.99) and 0.94 (0.89-0.99), respectively. But the intervention effect was not significant at the interpersonal level. The intervention effect at the organizational level was obvious, with an increase in opportunities for children and adolescents to acquire knowledge of infectious diseases from courses and lectures, teachers, and doctors, (all P < 0.05), with the ORs (95% CI) of 0.92 (0.87-0.97) and 0.86 (0.83-0.94), respectively. However, there was no significant difference between the intervention group and the control group in school infectious disease health education policy.

CONCLUSION

Enhancing health education regarding infectious diseases is crucial in promoting comprehensive prevention and control measures among children and adolescents. Nevertheless, it remains imperative to reinforce health education on infectious diseases at the interpersonal and policy levels. This holds significant reference value for mitigating childhood infectious diseases in the post-COVID-19 era.

Interventions to improve sanitation for preventing diarrhoea

BACKGROUND

Diarrhoea is a major contributor to the global disease burden, particularly amongst children under five years in low- and middle-income countries (LMICs). As many of the infectious agents associated with diarrhoea are transmitted through faeces, sanitation interventions to safely contain and manage human faeces have the potential to reduce exposure and diarrhoeal disease.

OBJECTIVES

To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease, alone or in combination with other WASH interventions.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and Chinese language databases available under the China National Knowledge Infrastructure (CNKI-CAJ). We also searched the metaRegister of Controlled Trials (mRCT) and conference proceedings, contacted researchers, and searched references of included studies. The last search date was 16 February 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs, non-randomized controlled trials (NRCTs), controlled before-and-after studies (CBAs), and matched cohort studies of interventions aimed at introducing or expanding the coverage and/or use of sanitation facilities in children and adults in any country or population. Our primary outcome of interest was diarrhoea and secondary outcomes included dysentery (bloody diarrhoea), persistent diarrhoea, hospital or clinical visits for diarrhoea, mortality, and adverse events. We included sanitation interventions whether they were conducted independently or in combination with other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligible studies, extracted relevant data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. We used meta-analyses to estimate pooled measures of effect, described results narratively, and investigated potential sources of heterogeneity using subgroup analyses.

MAIN RESULTS

Fifty-one studies met our inclusion criteria, with a total of 238,535 participants. Of these, 50 studies had sufficient information to be included in quantitative meta-analysis, including 17 cluster-RCTs and 33 studies with non-randomized study designs (20 NRCTs, one CBA, and 12 matched cohort studies). Most were conducted in LMICs and 86% were conducted in whole or part in rural areas. Studies covered three broad types of interventions: (1) providing access to any sanitation facility to participants without existing access practising open defecation, (2) improving participants' existing sanitation facility, or (3) behaviour change messaging to improve sanitation access or practices without providing hardware or subsidy, although many studies overlapped multiple categories. There was substantial heterogeneity amongst individual study results for all types of interventions. Providing access to any sanitation facility Providing access to sanitation facilities was evaluated in seven cluster-RCTs, and may reduce diarrhoea prevalence in all age groups (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.73 to 1.08; 7 trials, 40,129 participants, low-certainty evidence). In children under five years, access may have little or no effect on diarrhoea prevalence (RR 0.98, 95% CI 0.83 to 1.16, 4 trials, 16,215 participants, low-certainty evidence). Additional analysis in non-randomized studies was generally consistent with these findings. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.79, 95% CI 0.66 to 0.94; 15 studies, 73,511 participants; children < 5 years: RR 0.83, 95% CI 0.68 to 1.02; 11 studies, 25,614 participants).  Sanitation facility improvement Interventions designed to improve existing sanitation facilities were evaluated in three cluster-RCTs in children under five and may reduce diarrhoea prevalence (RR 0.85, 95% CI 0.69 to 1.06; 3 trials, 14,900 participants, low-certainty evidence). However, some of these interventions, such as sewerage connection, are not easily randomized. Non-randomized studies across participants of all ages provided estimates that improving sanitation facilities may reduce diarrhoea, but may be subject to confounding (RR 0.61, 95% CI 0.50 to 0.74; 23 studies, 117,639 participants, low-certainty evidence). Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.65, 95% CI 0.55 to 0.78; 26 studies, 132,539 participants; children < 5 years: RR 0.70, 95% CI 0.54 to 0.91, 12 studies, 23,353 participants).  Behaviour change messaging only (no hardware or subsidy provided) Strategies to promote behaviour change to construct, upgrade, or use sanitation facilities were evaluated in seven cluster-RCTs in children under five, and probably reduce diarrhoea prevalence (RR 0.82, 95% CI 0.69 to 0.98; 7 studies, 28,909 participants, moderate-certainty evidence). Additional analysis from two non-randomized studies found no effect, though with very high uncertainty. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (RR 0.85, 95% CI 0.73 to 1.01; 9 studies, 31,080 participants). No studies measured the effects of this type of intervention in older populations.  Any sanitation intervention A pooled analysis of cluster-RCTs across all sanitation interventions demonstrated that the interventions may reduce diarrhoea prevalence in all ages (RR 0.85, 95% CI 0.76 to 0.95, 17 trials, 83,938 participants, low-certainty evidence) and children under five (RR 0.87, 95% CI 0.77 to 0.97; 14 trials, 60,024 participants, low-certainty evidence). Non-randomized comparisons also demonstrated a protective effect, but may be subject to confounding. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.74, 95% CI 0.67 to 0.82; 50 studies, 237,130 participants; children < 5 years: RR 0.80, 95% CI 0.71 to 0.89; 32 studies, 80,047 participants). In subgroup analysis, there was some evidence of larger effects in studies with increased coverage amongst all participants (75% or higher coverage levels) and also some evidence that the effect decreased over longer follow-up times for children under five years. There was limited evidence on other outcomes. However, there was some evidence that any sanitation intervention was protective against dysentery (RR 0.74, 95% CI 0.54 to 1.00; 5 studies, 34,025 participants) and persistent diarrhoea (RR 0.57, 95% CI 0.43 to 0.75; 2 studies, 2665 participants), but not against clinic visits for diarrhoea (RR 0.86, 95% CI 0.44 to 1.67; 2 studies, 3720 participants) or all-cause mortality (RR 0.99, 95% CI 0.89 to1.09; 7 studies, 46,123 participants).

AUTHORS' CONCLUSIONS

There is evidence that sanitation interventions are effective at preventing diarrhoea, both for young children and all age populations. The actual level of effectiveness, however, varies by type of intervention and setting. There is a need for research to better understand the factors that influence effectiveness.

Water, sanitation and hygiene (WASH) in schools in Brazil pre-and peri-COVID-19 pandemic: Are schools making any progress?

The previous paucity of data and research on water, sanitation and hygiene (WASH) in schools in Brazil have been preventing an assessment of how safe and healthy schools are to reopen during the COVID-19 pandemic. This study aimed first to assess the current situation of WASH in schools in Brazil and, second, to evaluate to what extent Brazilian schools have been making any progress in providing WASH since the beginning of the COVID-19 pandemic. Data on WASH conditions in schools in Brazil was retrieved from the 2020 and 2021 Brazilian National School Census (BNSC). For the first objective, frequencies of 31 variables were calculated for the whole country and regions, considering all 173,700 schools from BNSC of 2021. Five main variables were considered as indicators of adequate WASH infrastructure in schools. T-test and ANOVA were used to assess differences in these five variables according to the locality, management model and regions. For the second objective only schools presented in both datasets (n = 170,422) were considered to compare WASH in schools pre- and peri-COVID-19 pandemic. Frequencies of 31 variables were calculated for the whole country and regions before and during the pandemic. Paired t-tests were conducted when differences in variables across the years were observed. At the present moment, the majority of schools in Brazil have bathrooms (97%), drinking water with quality suitable for human consumption (95%), improved sanitation facilities (78%) and solid waste collection (70%). Between 2020 and 2021, there was a mix of improvements and deterioration in the school's WASH infrastructure in all regions of the country. Overall, solely considering the WASH infrastructure, schools in the South and Southeast regions of the country are better prepared for the safe reopening. Nevertheless, public schools, schools located in rural areas and the North and Northeast regions of the country, are more in need of WASH interventions. Results indicate that little progress was achieved, and schools in Brazil are still in need of improvements.

Interventions for High-Burden Infectious Diseases in Children and Adolescents: A Meta-analysis

BACKGROUND

Approximately 2.2 million deaths were reported among school-age children and young people in 2019, and infectious diseases remain the leading causes of morbidity and mortality, especially in low and middle-income countries. We aim to synthesize evidence on interventions for high-burden infectious diseases among children and adolescents aged 5 to 19 years.

METHODS

We conducted a comprehensive literature search until December 31, 2020. Two review authors independently screened studies for relevance, extracted data, and assessed risk of bias.

RESULTS

We included a total of 31 studies, including 81 596 participants. Sixteen studies focused on diarrhea; 6 on tuberculosis; 2 on human immunodeficiency virus; 2 on measles; 1 study each on acute respiratory infections, malaria, and urinary tract infections; and 2 studies targeted multiple diseases. We did not find any study on other high burden infectious diseases among this age group. We could not perform meta-analysis for most outcomes because of variances in interventions and outcomes. Findings suggests that for diarrhea, water treatment, water filtration, and zinc supplementation have some protective effect. For tuberculosis, peer counseling, contingency contract, and training of health care workers led to improvements in tuberculosis detection and treatment completion. Continuation of cotrimoxazole therapy reduced the risk of tuberculosis and hospitalizations among human immunodeficiency virus-infected children and reduced measles complications and pneumonia cases among measles-infected children. Zinc supplementation led to a faster recovery in urinary tract infections with a positive effect in reducing symptoms.

CONCLUSIONS

There is scarcity of data on the effectiveness of interventions for high-burden infectious diseases among school-aged children and adolescents.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

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.

Knowledge, Practice of Personal Hygiene, School Sanitation, and Risk Factors of Contracting Diarrhea among Rural Students from Five Western Provinces in China

BACKGROUND

Diarrhea is a global public health issue and a leading cause of childhood malnutrition, growth disturbances, and mortality. The spread of diarrhea is closely linked to the knowledge and maintenance of personal hygiene and quality of drinking water and sanitation facilities. However, there are few such investigations and analysis in rural areas of China. This study aims to determine the association between the risk of contracting diarrhea and knowledge and practices of personal hygiene and school sanitation among rural students as well as provide a scientific basis for preventing the spread of diarrhea and other infectious diseases. A stratified cluster sampling method was used to randomly select 12 rural primary schools in each of 5 counties where the Water, Sanitation and Hygiene (WASH) Plus Program has been implemented. The counties are located in the Guangxi Zhuang autonomous region, Chongqing municipality, Guizhou province, Yunnan province, and Xinjiang Uygur autonomous region. A single fourth-grade class was randomly chosen from each of the 60 schools for observation and a questionnaire survey. The study involved a total of 2330 students. The logistic regression method was adopted to determine the factors contributing to diarrhea in rural students. The results show that male students accounted for 49.40% (n = 1151) of the 2330 research subjects; the average age of the students was 9.9 ± 0.3 years. Approximately 33.09% of the students suffered from diarrhea in the three months leading up to the survey. The odds ratios (ORs) of students who did not know that "diarrhea can be prevented by washing fruits before eating them raw and not drinking untreated water" (OR: 1.303, 95% confidence interval [CI]: 1.063, 1.597) and that "the disease can be prevented by washing hands before meals and after going to the toilet" (OR: 1.522, 95% CI: 1.207, 1.920) were higher than those who knew the above stated facts. Students who "have drunk untreated water at school" (OR: 1.584, 95% CI: 1.268, 1.978), "have drunk untreated water at home" (OR: 1.643, 95% CI: 1.319, 2.048), and "did not wash hands before every meal" (OR: 1.490, 95% CI: 1.120, 1.983) were at a higher risk of contracting diarrhea than those who drank treated water at school and at home and washed their hands before every meal. Diarrhea was more likely to affect students who attended schools with unclean and poorly maintained toilets (OR: 1.586, 95% CI: 1.261, 1.995) or toilets with flies (OR: 1.383, 95% CI: 1.114, 1.717) and without adequate drinking water facilities (OR: 1.407, 95% CI: 1.009, 1.962). The knowledge of methods to maintain personal hygiene, general hygiene practices, and school sanitation are the three major risk factors that account for the spread of diarrhea among rural students from five western provinces (municipalities and autonomous regions) of China. Therefore, to prevent such diseases and maintain health, it is important to provide students with health education, help them develop good hygiene habits, ensure the provision of clean water at schools, and improve the overall school environments.

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.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.