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Benjamin-Chung J, Nazneen A, Halder AK, Haque R, Siddique A, Uddin MS, Koporc K, Arnold BF, Hubbard AE, Unicomb L, Luby SP, Addiss DG, Colford JM. The Interaction of Deworming, Improved Sanitation, and Household Flooring with Soil-Transmitted Helminth Infection in Rural Bangladesh. PLoS Negl Trop Dis 2015; 9:e0004256. [PMID: 26624994 PMCID: PMC4666415 DOI: 10.1371/journal.pntd.0004256] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/02/2015] [Indexed: 11/18/2022] Open
Abstract
Background The combination of deworming and improved sanitation or hygiene may result in greater reductions in soil-transmitted helminth (STH) infection than any single intervention on its own. We measured STH prevalence in rural Bangladesh and assessed potential interactions among deworming, hygienic latrines, and household finished floors. Methodology We conducted a cross-sectional survey (n = 1,630) in 100 villages in rural Bangladesh to measure three exposures: self-reported deworming consumption in the past 6 months, access to a hygienic latrine, and household flooring material. We collected stool samples from children 1–4 years, 5–12 years, and women 15–49 years. We performed mini-FLOTAC on preserved stool samples to detect Ascaris lumbricoides, Enterobius vermicularis, hookworm, and Trichuris trichiura ova. Approximately one-third (32%) of all individuals and 40% of school-aged children had an STH infection. Less than 2% of the sample had moderate/heavy intensity infections. Deworming was associated with lower Ascaris prevalence (adjusted prevalence ratio (PR) = 0.53; 95% CI 0.40, 0.71), but there was no significant association with hookworm (PR = 0.93, 95% CI 0.60, 1.44) or Trichuris (PR = 0.90, 95% CI 0.74, 1.08). PRs for hygienic latrine access were 0.91 (95% CI 0.67,1.24), 0.73 (95% CI 0.43,1.24), and 1.03 (95% CI 0.84,1.27) for Ascaris, hookworm, and Trichuris, respectively. Finished floors were associated with lower Ascaris prevalence (PR = 0.56, 95% CI 0.32, 0.97) but not associated with hookworm (PR = 0.48 95% CI 0.16,1.45) or Trichuris (PR = 0.98, 95% CI 0.72,1.33). Across helminths and combinations of exposures, adjusted prevalence ratios for joint exposures were consistently more protective than those for individual exposures. Conclusions We found moderate STH prevalence in rural Bangladesh among children and women of childbearing age. This study is one of the first to examine independent and combined associations with deworming, sanitation, and hygiene. Our results suggest that coupling deworming with sanitation and flooring interventions may yield more sustained reductions in STH prevalence. Soil-transmitted helminth infections remain prevalent in many low-resource areas of the world. The World Health Organization recommends that schoolchildren in countries where these infections remain common receive deworming medication two times a year. However, previous research has shown that people who live in countries where these infections are common are frequently reinfected within 6 months of taking deworming medication. Programs that improve sanitation and hygiene might help complement deworming programs to reduce reinfection and prevent transmission. We conducted a survey of women and children in rural Bangladesh to understand potential sanitation and hygiene interventions that could complement deworming. We found that people who took deworming medication and had access to a hygienic latrine had a lower worm infection prevalence than people who only took deworming medication. We also found that people who took deworming medication and had a house with a finished floor had a lower prevalence than people who only took deworming medication. Our results suggest that coupling deworming with sanitation and flooring interventions may be a more successful strategy for reducing STH transmission in the long run.
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Affiliation(s)
- Jade Benjamin-Chung
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
- * E-mail:
| | - Arifa Nazneen
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Amal K. Halder
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abdullah Siddique
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Muhammed Salah Uddin
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Kim Koporc
- Children Without Worms, Task Force for Global Health, Atlanta, Georgia, United States of America
| | - Benjamin F. Arnold
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alan E. Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Leanne Unicomb
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephen P. Luby
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - David G. Addiss
- Children Without Worms, Task Force for Global Health, Atlanta, Georgia, United States of America
| | - John M. Colford
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
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Dreibelbis R, Jenkins M, Chase RP, Torondel B, Routray P, Boisson S, Clasen T, Freeman MC. Development of A Multidimensional Scale to Assess Attitudinal Determinants of Sanitation Uptake and Use. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2015; 49:13613-13621. [PMID: 26496245 DOI: 10.1021/acs.est.5b02985] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Over 1 billion people still practice open defecation. Low uptake and use of new sanitation technologies in a number of settings has underscored our current limited understanding of the complex attitudinal factors that influence a household's decision to adopt and use new sanitation technologies. Mokken scaling techniques were applied to series of population-based surveys in Odisha, India between September 2011 and October 2013 (sample sizes 120, 500, 2200). Surveys contained simple, agree/disagree statements about attitudes toward sanitation use and sanitation technologies. Analysis produced two scales-a 10-question General Scale, reflecting attitudes toward defecation and norms regarding latrine use for all respondents, and a 6-question Experiential Scale, reflecting personal experiences with and perceived convenience of sanitation technologies targeted at respondents with a latrine. Among all respondents, a one-point change in the General Scale was associated with a 5-percentage point change in the marginal probability of having access to a functioning latrine. Among respondents with a functional latrine at home, a one-point increase in the General and Experiential Scales were associated with a 4- and 8-percentage point decrease in the probability of engaging in any open defecation in the last 7 days, respectively.
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Affiliation(s)
- Robert Dreibelbis
- Civil Engineering and Environmental Science, University of Oklahoma , 201 Stephenson Parkway, Suite 4100, Norman, Oklahoma 73019, United States
| | - Marion Jenkins
- Department of Civil and Environmental Engineering, University of California Davis , One Shields Ave, Davis, California 95618, United States
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , Keppel St, London WC1E 7HT, U.K
| | - Rachel P Chase
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , 615 N. Wolfe St, Baltimore, Maryland 21205, United States
| | - Belen Torondel
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , Keppel St, London WC1E 7HT, U.K
| | - Parimita Routray
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , Keppel St, London WC1E 7HT, U.K
| | - Sophie Boisson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , Keppel St, London WC1E 7HT, U.K
| | - Thomas Clasen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , Keppel St, London WC1E 7HT, U.K
- Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, Georgia 30322, United States
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, Georgia 30322, United States
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Clasen TF, Alexander KT, Sinclair D, Boisson S, Peletz R, Chang HH, Majorin F, Cairncross S. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev 2015; 2015:CD004794. [PMID: 26488938 PMCID: PMC4625648 DOI: 10.1002/14651858.cd004794.pub3] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. In these settings, many infectious agents associated with diarrhoea are spread through water contaminated with faeces.In remote and low-income settings, source-based water quality improvement includes providing protected groundwater (springs, wells, and bore holes), or harvested rainwater as an alternative to surface sources (rivers and lakes). Point-of-use water quality improvement interventions include boiling, chlorination, flocculation, filtration, or solar disinfection, mainly conducted at home. OBJECTIVES To assess the effectiveness of interventions to improve water quality for preventing diarrhoea. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register (11 November 2014), CENTRAL (the Cochrane Library, 7 November 2014), MEDLINE (1966 to 10 November 2014), EMBASE (1974 to 10 November 2014), and LILACS (1982 to 7 November 2014). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies through 11 November 2014. SELECTION CRITERIA Randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies (CBA) comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS Forty-five cluster-RCTs, two quasi-RCTs, and eight CBA studies, including over 84,000 participants, met the inclusion criteria. Most included studies were conducted in low- or middle-income countries (LMICs) (50 studies) with unimproved water sources (30 studies) and unimproved or unclear sanitation (34 studies). The primary outcome in most studies was self-reported diarrhoea, which is at high risk of bias due to the lack of blinding in over 80% of the included studies. Source-based water quality improvementsThere is currently insufficient evidence to know if source-based improvements such as protected wells, communal tap stands, or chlorination/filtration of community sources consistently reduce diarrhoea (one cluster-RCT, five CBA studies, very low quality evidence). We found no studies evaluating reliable piped-in water supplies delivered to households. Point-of-use water quality interventionsOn average, distributing water disinfection products for use at the household level may reduce diarrhoea by around one quarter (Home chlorination products: RR 0.77, 95% CI 0.65 to 0.91; 14 trials, 30,746 participants, low quality evidence; flocculation and disinfection sachets: RR 0.69, 95% CI 0.58 to 0.82, four trials, 11,788 participants, moderate quality evidence). However, there was substantial heterogeneity in the size of the effect estimates between individual studies.Point-of-use filtration systems probably reduce diarrhoea by around a half (RR 0.48, 95% CI 0.38 to 0.59, 18 trials, 15,582 participants, moderate quality evidence). Important reductions in diarrhoea episodes were shown with ceramic filters, biosand systems and LifeStraw® filters; (Ceramic: RR 0.39, 95% CI 0.28 to 0.53; eight trials, 5763 participants, moderate quality evidence; Biosand: RR 0.47, 95% CI 0.39 to 0.57; four trials, 5504 participants, moderate quality evidence; LifeStraw®: RR 0.69, 95% CI 0.51 to 0.93; three trials, 3259 participants, low quality evidence). Plumbed in filters have only been evaluated in high-income settings (RR 0.81, 95% CI 0.71 to 0.94, three trials, 1056 participants, fixed effects model).In low-income settings, solar water disinfection (SODIS) by distribution of plastic bottles with instructions to leave filled bottles in direct sunlight for at least six hours before drinking probably reduces diarrhoea by around a third (RR 0.62, 95% CI 0.42 to 0.94; four trials, 3460 participants, moderate quality evidence).In subgroup analyses, larger effects were seen in trials with higher adherence, and trials that provided a safe storage container. In most cases, the reduction in diarrhoea shown in the studies was evident in settings with improved and unimproved water sources and sanitation. AUTHORS' CONCLUSIONS Interventions that address the microbial contamination of water at the point-of-use may be important interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections. The average estimates of effect for each individual point-of-use intervention generally show important effects. Comparisons between these estimates do not provide evidence of superiority of one intervention over another, as such comparisons are confounded by the study setting, design, and population.Further studies assessing the effects of household connections and chlorination at the point of delivery will help improve our knowledge base. As evidence suggests effectiveness improves with adherence, studies assessing programmatic approaches to optimising coverage and long-term utilization of these interventions among vulnerable populations could also help strategies to improve health outcomes.
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Affiliation(s)
- Thomas F Clasen
- Rollins School of Public Health, Emory UniversityDepartment of Environmental Health1518 Clifton Road NEAtlantaGAUSA30322
| | - Kelly T Alexander
- Rollins School of Public Health, Emory UniversityDepartment of Environmental Health1518 Clifton Road NEAtlantaGAUSA30322
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - Sophie Boisson
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesLondonUK
| | | | - Howard H Chang
- Rollins School of Public Health, Emory UniversityDepartment of Biostatistics and Bioinformatics1518 Clifton Road NEAtlantaGAUSA30322
| | - Fiona Majorin
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesLondonUK
| | - Sandy Cairncross
- London School of Hygiene & Tropical MedicineDepartment of Disease Control, Faculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
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Hunter PR, Risebro H, Yen M, Lefebvre H, Lo C, Hartemann P, Longuet C, Jaquenoud F. Impact of the Provision of Safe Drinking Water on School Absence Rates in Cambodia: A Quasi-Experimental Study. ANNALS OF NUTRITION AND METABOLISM 2015; 66 Suppl 3:31-7. [PMID: 26088045 DOI: 10.1159/000381244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Education is one of the most important drivers for helping people in developing countries lift themselves out of poverty. However, even when schooling is available absenteeism rates can be high. Recently, focus is being given on whether or not WASH interventions can help reduce absenteeism in developing countries. However, none has focused exclusively on the role of drinking water provision. We report a study on the association between absenteeism and provision of treated water in containers maintained in schools. METHODS AND FINDINGS We undertook a quasi-experimental longitudinal study of absenteeism rates in 8 schools, 4 of which received one 20 l container of treated drinking water per day. The water had been treated by filtration and ultraviolet disinfection. Weekly absenteeism rates were compared across all schools using the negative binomial model in generalized estimating equations. There was a strong association between the provision of free water and reduced absenteeism (Incidence rate ratio = 0.39 (95% confidence intervals 0.27-0.56)). However, there was also a strong association with season (wet versus dry) and a significant interaction between receiving free water and season. In one of the intervention schools, it was discovered that the water supplier was not fulfilling his contract and was not delivering sufficient water each week. In this school, we showed a significant association between the number of water containers delivered each week and absenteeism (IRR = 0.98 95% CI 0.96-1.00). CONCLUSION There appears to be a strong association between providing free and safe drinking water and reduced absenteeism, although only in the dry season. The mechanism for this association is not clear but may be in part due to improved hydration leading to improved school experience for the children.
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Affiliation(s)
- Paul R Hunter
- Norwich School of Medicine, University of East Anglia, Norwich, United Kingdom
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Jordanova T, Cronk R, Obando W, Medina OZ, Kinoshita R, Bartram J. Water, sanitation, and hygiene in schools in low socio-economic regions in Nicaragua: a cross-sectional survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:6197-217. [PMID: 26035665 PMCID: PMC4483696 DOI: 10.3390/ijerph120606197] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/25/2015] [Indexed: 11/16/2022]
Abstract
Water, sanitation, and hygiene (WaSH) in schools contributes to better health and educational outcomes among school-aged children. In 2012, UNICEF Nicaragua and partners conducted a cross-sectional survey of WaSH in 526 schools in 12 low socio-economic status municipalities in Nicaragua. The survey gathered information on: school characteristics; teacher and community participation; water and sanitation infrastructure; and hygiene education and habits. Survey results were analyzed for associations between variables. WaSH coverage was significantly higher in urban than rural areas. Presence of drinking water infrastructure (43%) was lower than sanitation infrastructure (64%). Eighty-one percent of schools had no hand washing stations and 74% of schools lacked soap. Sanitation facilities were not in use at 28% of schools with sanitation infrastructure and 26% of schools with water infrastructure had non-functional systems. Only 8% of schools had budgets to purchase toilet-cleaning supplies and 75% obtained supplies from students’ families. This study generates transferable WaSH sector learnings and new insights from monitoring data. Results can be used by donors, service providers, and policy makers to better target resources in Nicaraguan schools.
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Affiliation(s)
- Tania Jordanova
- Department of Environmental Sciences and Engineering, The Water Institute, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Ryan Cronk
- Department of Environmental Sciences and Engineering, The Water Institute, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Wanda Obando
- The United Nations Children's Fund (UNICEF), Managua 10000, Nicaragua.
| | | | - Rinko Kinoshita
- The United Nations Children's Fund (UNICEF), Managua 10000, Nicaragua.
| | - Jamie Bartram
- Department of Environmental Sciences and Engineering, The Water Institute, University of North Carolina, Chapel Hill, NC 27599, USA.
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Corburn J, Hildebrand C. Slum Sanitation and the Social Determinants of Women's Health in Nairobi, Kenya. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2015; 2015:209505. [PMID: 26060499 PMCID: PMC4427764 DOI: 10.1155/2015/209505] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 11/18/2022]
Abstract
Inadequate urban sanitation disproportionately impacts the social determinants of women's health in informal settlements or slums. The impacts on women's health include infectious and chronic illnesses, violence, food contamination and malnutrition, economic and educational attainment, and indignity. We used household survey data to report on self-rated health and sociodemographic, housing, and infrastructure conditions in the Mathare informal settlement in Nairobi, Kenya. We combined quantitative survey and mapping data with qualitative focus group information to better understand the relationships between environmental sanitation and the social determinants of women and girls' health in the Mathare slum. We find that an average of eighty-five households in Mathare share one toilet, only 15% of households have access to a private toilet, and the average distance to a public toilet is over 52 meters. Eighty-three percent of households without a private toilet report poor health. Mathare women report violence (68%), respiratory illness/cough (46%), diabetes (33%), and diarrhea (30%) as the most frequent physical burdens. Inadequate, unsafe, and unhygienic sanitation results in multiple and overlapping health, economic, and social impacts that disproportionately impact women and girls living in urban informal settlements.
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Affiliation(s)
- Jason Corburn
- School of Public Health and Department of City and Regional Planning, University of California, Berkeley, Berkeley, CA 94720, USA
| | - Chantal Hildebrand
- School of Public Health, University of California, Berkeley, Berkeley, CA 94720, USA
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Pfadenhauer LM, Rehfuess E. Towards effective and socio-culturally appropriate sanitation and hygiene interventions in the Philippines: a mixed method approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:1902-27. [PMID: 25664699 PMCID: PMC4344701 DOI: 10.3390/ijerph120201902] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 01/04/2015] [Accepted: 02/02/2015] [Indexed: 02/05/2023]
Abstract
Inadequate water, sanitation and hygiene (WASH) represent an important health burden in the Philippines. The non-governmental organisation Fit for School intends to complement its handwashing programme in schools with sanitation interventions. The objectives of this mixed-method study therefore were to describe WASH practices and their impact on childhood diarrhoea in the Philippines, and to examine socio-cultural and environmental factors underlying defecation and anal cleansing practices in Northern Mindanao. We quantified the effect of WASH practices on diarrhoea through logistic regression models, using the Philippine Demographic and Health Survey 2008. When adjusting for non-modifiable factors, susceptibility and socioeconomic factors, WASH factors failed to show a statistically significant effect. Focus group discussions were held with women in urban and rural Northern Mindanao, and findings analysed using thematic analysis. Defecation and anal cleansing behaviours were constrained by the physical environment, particularly the lack of clean, safe, comfortable and private facilities. Individual determinants of behaviour were influenced by habit and motivations such as disgust, with some evidence of planned behaviour. Where available, water was the preferred material for anal cleansing. This study combines nationally-representative quantitative data with local in-depth qualitative insights, constituting critical formative research in the development of effective and appropriate interventions.
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Affiliation(s)
- Lisa Maria Pfadenhauer
- Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
| | - Eva Rehfuess
- Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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Factors associated with pupil toilet use in kenyan primary schools. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:9694-711. [PMID: 25233014 PMCID: PMC4199044 DOI: 10.3390/ijerph110909694] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/09/2014] [Accepted: 09/10/2014] [Indexed: 11/16/2022]
Abstract
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.
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Caruso BA, Freeman MC, Garn JV, Dreibelbis R, Saboori S, Muga R, Rheingans R. Assessing the impact of a school-based latrine cleaning and handwashing program on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health 2014; 19:1185-97. [PMID: 25055716 DOI: 10.1111/tmi.12360] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Improving school water, sanitation and hygiene (WASH) conditions reduces pupil absence and illness. However, these benefits may depend on the conditions of the latrines and availability of consumables. We sought to determine whether a low-cost, policy-relevant, environmental-level latrine cleaning intervention could improve latrine cleanliness, increase its use and reduce absenteeism. METHODS In a three-arm, cluster-randomized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project. Latrine conditions and use were also assessed using structured observation. Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls, as did handwashing with soap. We found no difference in latrine use and absence across arms. CONCLUSIONS The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received. Improving latrine conditions is important for the dignity and well-being of pupils, and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly.
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Affiliation(s)
- Bethany A Caruso
- Department of Behavioral Sciences and Health Education, Emory University, Atlanta, GA, USA; Center for Global Safe Water at Emory University, Atlanta, GA, USA
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Oduwo E, Edwards SJL. A systematic review of factors affecting children's right to health in cluster randomized trials in Kenya. Trials 2014; 15:287. [PMID: 25027410 PMCID: PMC4223386 DOI: 10.1186/1745-6215-15-287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/01/2014] [Indexed: 11/10/2022] Open
Abstract
Following the South African case, Treatment Action Campaign and Others v Minister of Health and Others, the use of 'pilot' studies to investigate interventions already proven efficacious, offered free of charge to government, but confined by the government to a small part of the population, may violate children's right to health, and the negative duty on governments not to prevent access to treatment. The applicants challenged a government decision to offer Nevirapine in a few pilot sites when evidence showed Nevirapine significantly reduced HIV transmission rates and despite donor offers of a free supply. The government refused to expand access, arguing they needed to collect more information, and citing concerns about long-term hazards, side effects, resistance and inadequate infrastructure. The court ruled this violated children's right to health and asked the government to immediately expand access. Cluster randomized trials involving children are increasingly popular, and are often used to reduce 'contamination': the possibility that members of a cluster adopt behavior of other clusters. However, they raise unique issues insufficiently addressed in literature and ethical guidelines. This case provides additional crucial guidance, based on a common human rights framework, for the Kenyan government and other involved stakeholders. Children possess special rights, often represent a 'captive' group, and so motivate extra consideration. In a systematic review, we therefore investigated whether cluster trial designs are used to prevent or delay children's access to treatment in Kenya or otherwise inconsistently with children's right to health as outlined in the above case. Although we did not find state sponsored cluster trials, most had significant public sector involvement. Core obligations under children's right to health were inadequately addressed across trials. Few cluster trials reported rationale for cluster randomization, offered post- trial access or planned to implement successful interventions. A small number of trials may have unnecessarily evaluated proven interventions, offered their control arm trial conditions worse than local standards of care or evaluated interventions ostensibly worse than local standards of care. Further research is required to establish if children's right to health in cluster trials is well understood and to explain why some obligations are unmet.
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Hunter PR, Risebro H, Yen M, Lefebvre H, Lo C, Hartemann P, Longuet C, Jaquenoud F. Impact of the provision of safe drinking water on school absence rates in Cambodia: a quasi-experimental study. PLoS One 2014; 9:e91847. [PMID: 24632573 PMCID: PMC3954794 DOI: 10.1371/journal.pone.0091847] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 02/16/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Education is one of the most important drivers behind helping people in developing countries lift themselves out of poverty. However, even when schooling is available absenteeism rates can be high. Recently interest has focussed on whether or not WASH interventions can help reduce absenteeism in developing countries. However, none has focused exclusively on the role of drinking water provision. We report a study of the association between absenteeism and provision of treated water in containers into schools. METHODS AND FINDINGS We undertook a quasi-experimental longitudinal study of absenteeism rates in 8 schools, 4 of which received one 20 L container of treated drinking water per day. The water had been treated by filtration and ultraviolet disinfection. Weekly absenteeism rates were compared across all schools using negative binomial model in generalized estimating equations. There was a strong association with provision of free water and reduced absenteeism (Incidence rate ratio = 0.39 (95% Confidence Intervals 0.27-0.56)). However there was also a strong association with season (wet versus dry) and a significant interaction between receiving free water and season. In one of the intervention schools it was discovered that the water supplier was not fulfilling his contract and was not delivering sufficient water each week. In this school we showed a significant association between the number of water containers delivered each week and absenteeism (IRR = 0.98 95%CI 0.96-1.00). CONCLUSION There appears to be a strong association between providing free safe drinking water and reduced absenteeism, though only in the dry season. The mechanism for this association is not clear but may in part be due to improved hydration leading to improved school experience for the children.
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Affiliation(s)
- Paul R. Hunter
- Norwich School of Medicine, University of East Anglia, Norwich, United Kingdom
- * E-mail:
| | - Helen Risebro
- Norwich School of Medicine, University of East Anglia, Norwich, United Kingdom
| | - Marie Yen
- 1001 fontaines pour demain, Caluire et Cuire, France
| | | | - Chay Lo
- Teuk Saat 1001, Phnom Penh, Cambodia
| | - Philippe Hartemann
- Département Environnement et Santé Publique, Faculté de médecine de Nancy - Université de Lorraine, Nancy, France
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Impact of water, sanitation, and hygiene interventions on improving health outcomes among school children. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2013; 2013:984626. [PMID: 24454415 PMCID: PMC3888759 DOI: 10.1155/2013/984626] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/27/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE This review was done to explore the impact of water treatment, hygiene, and sanitary interventions on improving child health outcomes such as absenteeism, infections, knowledge, attitudes, and practices and adoption of point-of-use water treatment. METHODS A literature search was conducted using the databases PubMed and Google scholar for studies published between 2009 and 2012 and focusing on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children. Studies included were those that documented the provision of water and sanitation in schools for children less than 18 years of age, interventions which assessed WASH practices, and English-language, full-text peer reviewed papers. RESULTS Fifteen studies were included in the final analysis. 73% (n = 11) of the studies were conducted in developing countries and were rural based (53%, n = 8). The child's age, gender, grade level, socioeconomic index, access to hygiene and sanitary facilities, and prior knowledge of hygiene practices were significantly associated with the outcomes. Nutrition practices which are key factors associated with the outcomes were rarely assessed. CONCLUSION Further research is required to assess the long-term impact of such interventions in different settings.
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Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster-randomized trial in Kenya. Am J Public Health 2013; 104:e91-7. [PMID: 24228683 DOI: 10.2105/ajph.2013.301412] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the impact of school water, sanitation, and hygiene (WASH) interventions on diarrhea-related outcomes among younger siblings of school-going children. METHODS We conducted a cluster-randomized trial among 185 schools in Kenya from 2007 to 2009. We assigned schools to 1 of 2 study groups according to water availability. Multilevel logistic regression models, adjusted for baseline measures, assessed differences between intervention and control arms in 1-week period prevalence of diarrhea and 2-week period prevalence of clinic visits among children younger than 5 years with at least 1 sibling attending a program school. RESULTS Among water-scarce schools, comprehensive WASH improvements were associated with decreased odds of diarrhea (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.27, 0.73) and visiting a clinic (OR = 0.36; 95% CI = 0.19, 0.68), relative to control schools. In our separate study group of schools with greater water availability, school hygiene promotion and water treatment interventions and school sanitation improvements were not associated with differences in diarrhea prevalence between intervention and control schools. CONCLUSIONS In water-scarce areas, school WASH interventions that include robust water supply improvements can reduce diarrheal diseases among young children.
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Affiliation(s)
- Robert Dreibelbis
- Robert Dreibelbis is with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Robert Dreibelbis is also with the Hubert Department of Global Health, and Matthew C. Freeman, Leslie E. Greene, and Shadi Saboori are with the Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA. Richard Rheingans is with the Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville
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Freeman MC, Clasen T, Brooker SJ, Akoko DO, Rheingans R. The impact of a school-based hygiene, water quality and sanitation intervention on soil-transmitted helminth reinfection: a cluster-randomized trial. Am J Trop Med Hyg 2013; 89:875-83. [PMID: 24019429 PMCID: PMC3820330 DOI: 10.4269/ajtmh.13-0237] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/13/2013] [Indexed: 11/07/2022] Open
Abstract
We conducted a cluster-randomized trial to assess the impact of a school-based water treatment, hygiene, and sanitation program on reducing infection with soil-transmitted helminths (STHs) after school-based deworming. We assessed infection with STHs at baseline and then at two follow-up rounds 8 and 10 months after deworming. Forty government primary schools in Nyanza Province, Kenya were randomly selected and assigned to intervention or control arms. The intervention reduced reinfection prevalence (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.31-1.00) and egg count (rate ratio [RR] 0.34, CI 0.15-0.75) of Ascaris lumbricoides. We found no evidence of significant intervention effects on the overall prevalence and intensity of Trichuris trichiura, hookworm, or Schistosoma mansoni reinfection. Provision of school-based sanitation, water quality, and hygiene improvements may reduce reinfection of STHs after school-based deworming, but the magnitude of the effects may be sex- and helminth species-specific.
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Affiliation(s)
- Matthew C. Freeman
- Emory University, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, London, United Kingdom; Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Great Lakes University of Kisumu, Kisumu, Kenya; University of Florida, Gainesville, Florida
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Erhard L, Degabriele J, Naughton D, Freeman MC. Policy and provision of WASH in schools for children with disabilities: A case study in Malawi and Uganda. Glob Public Health 2013; 8:1000-13. [DOI: 10.1080/17441692.2013.838284] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, Amnie AG, Beckwith C, Cairncross S, Callejas R, Colford JM, Emerson PM, Fenwick A, Fishman R, Gallo K, Grimes J, Karapetyan G, Keene B, Lammie PJ, MacArthur C, Lochery P, Petach H, Platt J, Prabasi S, Rosenboom JW, Roy S, Saywell D, Schechtman L, Tantri A, Velleman Y, Utzinger J. Integration of water, sanitation, and hygiene for the prevention and control of neglected tropical diseases: a rationale for inter-sectoral collaboration. PLoS Negl Trop Dis 2013; 7:e2439. [PMID: 24086781 PMCID: PMC3784463 DOI: 10.1371/journal.pntd.0002439] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Improvements of water, sanitation, and hygiene (WASH) infrastructure and appropriate health-seeking behavior are necessary for achieving sustained control, elimination, or eradication of many neglected tropical diseases (NTDs). Indeed, the global strategies to fight NTDs include provision of WASH, but few programs have specific WASH targets and approaches. Collaboration between disease control programs and stakeholders in WASH is a critical next step. A group of stakeholders from the NTD control, child health, and WASH sectors convened in late 2012 to discuss opportunities for, and barriers to, collaboration. The group agreed on a common vision, namely "Disease-free communities that have adequate and equitable access to water and sanitation, and that practice good hygiene." Four key areas of collaboration were identified, including (i) advocacy, policy, and communication; (ii) capacity building and training; (iii) mapping, data collection, and monitoring; and (iv) research. We discuss strategic opportunities and ways forward for enhanced collaboration between the WASH and the NTD sectors.
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Affiliation(s)
- Matthew C. Freeman
- Department of Environmental Health, Emory University, Atlanta, Georgia, United States of America
| | - Stephanie Ogden
- Department of Environmental Health, Emory University, Atlanta, Georgia, United States of America
- Children Without Worms, Taskforce for Global Health, Atlanta, Georgia, United States of America
- International Trachoma Initiative, Taskforce for Global Health, Atlanta, Georgia, United States of America
| | - Julie Jacobson
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Daniel Abbott
- Save the Children, Washington, D.C., United States of America
| | - David G. Addiss
- Children Without Worms, Taskforce for Global Health, Atlanta, Georgia, United States of America
| | - Asrat G. Amnie
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, United States of America
| | - Colin Beckwith
- International Trachoma Initiative, Taskforce for Global Health, Atlanta, Georgia, United States of America
| | - Sandy Cairncross
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rafael Callejas
- Millennium Water Alliance, Washington, D.C., United States of America
| | - Jack M. Colford
- Department of Epidemiology, University of California-Berkeley, Berkeley, California, United States of America
| | - Paul M. Emerson
- The Carter Center, Atlanta, Georgia, United States of America
| | - Alan Fenwick
- Schistosomiasis Control Initiative, Imperial College, London, United Kingdom
| | | | - Kerry Gallo
- Children Without Worms, Taskforce for Global Health, Atlanta, Georgia, United States of America
| | - Jack Grimes
- Schistosomiasis Control Initiative, Imperial College, London, United Kingdom
- Department of Civil and Environmental Engineering, Imperial College, London, United Kingdom
| | | | - Brooks Keene
- CARE International, Atlanta, Georgia, United States of America
| | - Patrick J. Lammie
- Taskforce for Global Health, Atlanta, Georgia, United States of America
- Center for Global Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Chad MacArthur
- Helen Keller International, New York, New York, United States of America
| | - Peter Lochery
- CARE International, Atlanta, Georgia, United States of America
| | - Helen Petach
- United States Agency for International Development, Washington, D.C., United States of America
| | - Jennifer Platt
- WASH Advocates, Washington, D.C., United States of America
| | - Sarina Prabasi
- ORBIS International, New York, New York, United States of America
| | | | - Sharon Roy
- Waterborne Disease Prevention Branch, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Darren Saywell
- Plan International, Washington, D.C., United States of America
| | - Lisa Schechtman
- WaterAid America, Washington, D.C., United States of America
| | - Anupama Tantri
- Sabin Vaccine Institute, Washington, D.C., United States of America
| | | | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Chittleborough CR, Nicholson AL, Young E, Bell S, Campbell R. Implementation of an educational intervention to improve hand washing in primary schools: process evaluation within a randomised controlled trial. BMC Public Health 2013; 13:757. [PMID: 23947388 PMCID: PMC3751660 DOI: 10.1186/1471-2458-13-757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 07/31/2013] [Indexed: 11/22/2022] Open
Abstract
Background Process evaluations are useful for understanding how interventions are implemented in trial settings. This is important for interpreting main trial results and indicating how the intervention might function beyond the trial. The purpose of this study was to examine the reach, dose, fidelity, acceptability, and sustainability of the implementation of an educational hand washing intervention in primary schools, and to explore views regarding acceptability and sustainability of the intervention. Methods Process evaluation within a cluster randomised controlled trial, including focus groups with pupils aged 6 to 11, semi-structured interviews with teachers and external staff who coordinated the intervention delivery, and school reports and direct observations of the intervention delivery. Results The educational package was delivered in 61.4% of schools (85.2% of intervention schools, 37.8% of control schools following completion of the trial). Teachers and pupils reacted positively to the intervention, although concerns were raised about the age-appropriateness of the resources. Teachers adapted the resources to suit their school setting and pupils. Staff coordinating the intervention delivery had limited capacity to follow up and respond to schools. Conclusions The hand washing intervention was acceptable to schools, but its reach outside of a randomised trial, evidenced in the low proportion of schools in the control arm who received it after the trial had ended, suggests that the model of delivery may not be sustainable. Trial registration ISRCTN: ISRCTN93576146
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Affiliation(s)
- Catherine R Chittleborough
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol BS8 2PS, United Kingdom.
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Saboori S, Greene LE, Moe CL, Freeman MC, Caruso BA, Akoko D, Rheingans RD. 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. Am J Trop Med Hyg 2013; 89:698-708. [PMID: 23939707 PMCID: PMC3795100 DOI: 10.4269/ajtmh.12-0387] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Shadi Saboori
- *Address correspondence to Shadi Saboori, Center for Global Safe Water, Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322. E-mail:
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Pickering AJ, Davis J, Blum AG, Scalmanini J, Oyier B, Okoth G, Breiman RF, Ram PK. Access to waterless hand sanitizer improves student hand hygiene behavior in primary schools in Nairobi, Kenya. Am J Trop Med Hyg 2013; 89:411-8. [PMID: 23836575 DOI: 10.4269/ajtmh.13-0008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Handwashing is difficult in settings with limited resources and water access. In primary schools within urban Kibera, Kenya, we investigated the impact of providing waterless hand sanitizer on student hand hygiene behavior. Two schools received a waterless hand sanitizer intervention, two schools received a handwashing with soap intervention, and two schools received no intervention. Hand cleaning behavior after toilet use was monitored for 2 months using structured observation. Hand cleaning after toileting was 82% at sanitizer schools (N = 2,507 toileting events), 38% at soap schools (N = 3,429), and 37% at control schools (N = 2,797). Students at sanitizer schools were 23% less likely to have observed rhinorrhea than control students (P = 0.02); reductions in student-reported gastrointestinal and respiratory illness symptoms were not statistically significant. Providing waterless hand sanitizer markedly increased student hand cleaning after toilet use, whereas the soap intervention did not. Waterless hand sanitizer may be a promising option to improve student hand cleansing behavior, particularly in schools with limited water access.
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Affiliation(s)
- Amy J Pickering
- Civil and Environmental Engineering and Woods Institute for the Environment, Stanford University, Stanford, CA, USA.
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Clasen T, Boisson S, Routray P, Cumming O, Jenkins M, Ensink JHJ, Bell M, Freeman MC, Peppin S, Schmidt WP. The effect of improved rural sanitation on diarrhoea and helminth infection: design of a cluster-randomized trial in Orissa, India. Emerg Themes Epidemiol 2012; 9:7. [PMID: 23148587 PMCID: PMC3558431 DOI: 10.1186/1742-7622-9-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 11/01/2012] [Indexed: 11/23/2022] Open
Abstract
Background Infectious diseases associated with poor sanitation such as diarrhoea, intestinal worms, trachoma and lymphatic filariasis continue to cause a large disease burden in low income settings and contribute substantially to child mortality and morbidity. Obtaining health impact data for rural sanitation campaigns poses a number of methodological challenges. Here we describe the design of a village-level cluster-randomised trial in the state of Orissa, India to evaluate the impact of an ongoing rural sanitation campaign conducted under the umbrella of India’s Total Sanitation Campaign (TSC).We randomised 50 villages to the intervention and 50 villages to control. In the intervention villages the implementing non-governmental organisations conducted community mobilisation and latrine construction with subsidies given to poor families. Control villages receive no intervention. Outcome measures include (1) diarrhoea in children under 5 and in all ages, (2) soil-transmitted helminth infections, (3) anthropometric measures, (4) water quality, (5) number of insect vectors (flies, mosquitoes), (6) exposure to faecal pathogens in the environment. In addition we are conducting process documentation (latrine construction and use, intervention reach), cost and cost-effectiveness analyses, spatial analyses and qualitative research on gender and water use for sanitation. Results Randomisation resulted in an acceptable balance between trial arms. The sample size requirements appear to be met for the main study outcomes. Delays in intervention roll-out caused logistical problems especially for the planning of health outcome follow-up surveys. Latrine coverage at the end of the construction period (55%) remained below the target of 70%, a result that may, however, be in line with many other TSC intervention areas in India. Conclusion We discuss a number of methodological problems encountered thus far in this study that may be typical for sanitation trials. Nevertheless, it is expected that the trial procedures will allow measuring the effectiveness of a typical rural sanitation campaign, with sufficient accuracy and validity.
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Affiliation(s)
- Thomas Clasen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
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71
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Overgaard HJ, Alexander N, Mátiz MI, Jaramillo JF, Olano VA, Vargas S, Sarmiento D, Lenhart A, Seidu R, Stenström TA. Diarrhea and dengue control in rural primary schools in Colombia: study protocol for a randomized controlled trial. Trials 2012; 13:182. [PMID: 23034084 PMCID: PMC3582494 DOI: 10.1186/1745-6215-13-182] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/24/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diarrheal diseases and dengue fever are major global health problems. Where provision of clean water is inadequate, water storage is crucial. Fecal contamination of stored water is a common source of diarrheal illness, but stored water also provides breeding sites for dengue vector mosquitoes. Poor household water management and sanitation are therefore potential determinants of both diseases. Little is known of the role of stored water for the combined risk of diarrhea and dengue, yet a joint role would be important for developing integrated control and management efforts. Even less is known of the effect of integrating control of these diseases in school settings. The objective of this trial was to investigate whether interventions against diarrhea and dengue will significantly reduce diarrheal disease and dengue entomological risk factors in rural primary schools. METHODS/DESIGN This is a 2×2 factorial cluster randomized controlled trial. Eligible schools were rural primary schools in La Mesa and Anapoima municipalities, Cundinamarca, Colombia. Eligible pupils were school children in grades 0 to 5. Schools were randomized to one of four study arms: diarrhea interventions (DIA); dengue interventions (DEN); combined diarrhea and dengue interventions (DIADEN); and control (C). Schools were allocated publicly in each municipality (strata) at the start of the trial, obviating the need for allocation concealment. The primary outcome for diarrhea is incidence rate of diarrhea in school children and for dengue it is density of adult female Aedes aegypti per school. Approximately 800 pupils from 34 schools were enrolled in the trial with eight schools in the DIA arm, nine in the DEN, eight in the DIADEN, and nine in the control arms. The trial status as of June 2012 was: completed baseline data collections; enrollment, randomization, and allocation of schools. The trial was funded by the Research Council of Norway and the Lazos de Calandaima Foundation. DISCUSSION This is the first trial investigating the effect of a set of integrated interventions to control both dengue and diarrhea. This is also the first trial to study the combination of diarrhea-dengue disease control in school settings. TRIAL REGISTRATION Current Controlled Trials ISRCTN40195031.
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Affiliation(s)
- Hans J Overgaard
- Department of Mathematical Sciences and Technology, Norwegian University of Life Sciences, Ås, Norway
| | - Neal Alexander
- London School of Hygiene and Tropical Medicine, London, UK
| | - Maria Ines Mátiz
- Instituto de Salud y Ambiente, Universidad El Bosque, Bogotá, Colombia
| | | | | | - Sandra Vargas
- Instituto de Salud y Ambiente, Universidad El Bosque, Bogotá, Colombia
| | - Diana Sarmiento
- Instituto de Salud y Ambiente, Universidad El Bosque, Bogotá, Colombia
| | | | - Razak Seidu
- Department of Mathematical Sciences and Technology, Norwegian University of Life Sciences, Ås, Norway
| | - Thor Axel Stenström
- Department of Mathematical Sciences and Technology, Norwegian University of Life Sciences, Ås, Norway
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Patel MK, Harris JR, Juliao P, Nygren B, Were V, Kola S, Sadumah I, Faith SH, Otieno R, Obure A, Hoekstra RM, Quick R. Impact of a hygiene curriculum and the installation of simple handwashing and drinking water stations in rural Kenyan primary schools on student health and hygiene practices. Am J Trop Med Hyg 2012; 87:594-601. [PMID: 22869631 DOI: 10.4269/ajtmh.2012.11-0494] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
School-based hygiene and water treatment programs increase student knowledge, improve hygiene, and decrease absenteeism, however health impact studies of these programs are lacking. We collected baseline information from students in 42 schools in Kenya. We then instituted a curriculum on safe water and hand hygiene and installed water stations in half ("intervention schools"). One year later, we implemented the intervention in remaining schools. Through biweekly student household visits and two annual surveys, we compared the effect of the intervention on hygiene practices and reported student illness. We saw improvement in proper handwashing techniques after the school program was introduced. We observed a decrease in the median percentage of students with acute respiratory illness among those exposed to the program; no decrease in acute diarrhea was seen. Students in this school program exhibited sustained improvement in hygiene knowledge and a decreased risk of respiratory infections after the intervention.
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Affiliation(s)
- Minal K Patel
- Epidemic Intelligence Service and Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Jasper C, Le TT, Bartram J. Water and sanitation in schools: a systematic review of the health and educational outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2012; 9:2772-87. [PMID: 23066396 PMCID: PMC3447586 DOI: 10.3390/ijerph9082772] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/14/2012] [Accepted: 07/17/2012] [Indexed: 11/30/2022]
Abstract
A systematic review of the literature on the effects of water and sanitation in schools was performed. The goal was to characterize the impacts of water and sanitation inadequacies in the academic environment. Published peer reviewed literature was screened and articles that documented the provision of water and sanitation at schools were considered. Forty-one peer-reviewed papers met the criteria of exploring the effects of the availability of water and/or sanitation facilities in educational establishments. Chosen studies were divided into six fields based on their specific foci: water for drinking, water for handwashing, water for drinking and handwashing, water for sanitation, sanitation for menstruation and combined water and sanitation. The studies provide evidence for an increase in water intake with increased provision of water and increased access to water facilities. Articles also report an increase in absenteeism from schools in developing countries during menses due to inadequate sanitation facilities. Lastly, there is a reported decrease in diarrheal and gastrointestinal diseases with increased access to adequate sanitation facilities in schools. Ensuring ready access to safe drinking water, and hygienic toilets that offer privacy to users has great potential to beneficially impact children's health. Additional studies that examine the relationship between sanitation provisions in schools are needed to more adequately characterize the impact of water and sanitation on educational achievements.
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Affiliation(s)
- Christian Jasper
- The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7431, Chapel Hill, NC 27599, USA;
| | - Thanh-Tam Le
- Department of Biology, University of North Carolina at Chapel Hill, 120 South Road, Chapel Hill, NC 27599, USA;
| | - Jamie Bartram
- The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7431, Chapel Hill, NC 27599, USA;
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Greene LE, Freeman MC, Akoko D, Saboori S, Moe C, Rheingans R. Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial. Am J Trop Med Hyg 2012; 87:385-393. [PMID: 22802437 PMCID: PMC3435337 DOI: 10.4269/ajtmh.2012.11-0633] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Handwashing with soap effectively reduces exposure to diarrhea-causing pathogens. Interventions to improve hygiene and sanitation conditions in schools within low-income countries have gained increased attention; however, their impact on schoolchildren's exposure to fecal pathogens has not been established. Our trial examined whether a school-based water, sanitation, and hygiene intervention reduced Escherichia coli contamination on pupils' hands in western Kenya. A hygiene promotion and water treatment intervention did not reduce risk of E. coli presence (relative risk [RR] = 0.92, 95% confidence interval [CI] = 0.54–1.56); the addition of new latrines to intervention schools significantly increased risk among girls (RR = 2.63, 95% CI = 1.29–5.34), with a non-significant increase among boys (RR = 1.36, 95% CI = 0.74–2.49). Efforts to increase usage of school latrines by constructing new facilities may pose a risk to children in the absence of sufficient hygiene behavior change, daily provision of soap and water, and anal cleansing materials.
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Affiliation(s)
- Leslie E. Greene
- *Address correspondence to Leslie E. Greene, Center for Global Safe Water, Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, CNR #2027, Atlanta, GA 30322. E-mail:
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