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

Handwashing Practices among Public Primary School Students in East Dembiya District, Ethiopia

Poor water sanitation and hygiene is a public health problem in developing and underdeveloped countries, including Ethiopia, and remains an important public health issue among primary school students. Students have been repeatedly exposed to various communicable diseases associated with water sanitation and hygiene. The objective of this study was to assess predictors of handwashing practice among second-cycle public primary school students in East Dembiya District, northwestern Ethiopia, 2022. A cross-sectional study was conducted among 752 second-cycle primary school students. Data were gathered through face-to-face interviews using a structured interviewer-administered questionnaire and observational checklists adopted and modified from different sources of literature. The data were checked further by visualizing and computing rates with the SPSS version 26 statistical software. Multivariable logistic regression was used to identify predictors. The prevalence of washing practices among second-cycle primary school students was 57.6% (95% CI 53.90-61.10). Residency (urban) (adjusted odds ratio [aOR] = 2.17, 95% CI: 1.30-2.87), access to media (aOR = 1.66, 95% CI: 1.11-2.49), hygiene and sanitation club membership (aOR = 1.88, 95% CI: 1.26-2.80), good knowledge about handwashing (aOR = 3.93, 95% CI: 2.34-6.60), and a positive attitude toward handwashing (aOR = 3.63, 95% CI: 2.01-5.584) were predictors of handwashing practice among second-cycle primary school students. This study showed that handwashing practice among primary school students was low. Availing handwashing facilities, better media access, formation of a hygiene and sanitation club in the school, celebration of "Handwashing Day" with students, and leading behavior change communication are all important for improving students' handwashing practice.

Making Germs Visible - Assessing the Impact of a School-Based, Low-Cost Intervention on Hand Hygiene Knowledge, Attitude and Practice of Children in Rural India

Handwashing with soap at critical moments is one of the most important factors in controlling the spread of germs and preventing the spread of infection. The objective of this study was to determine the effectiveness of a low-cost, school-based intervention that simulated germs and their spread on hand hygiene knowledge, attitude and practice of primary school children. Five hundred and sixty-two students from 28 rural schools were enrolled in this pre-posttest study. Endline data was collected 4 weeks after conducting the intervention at baseline. The mean scores for knowledge, attitude and practice improved significantly after the intervention (p < .05). Significant positive gains were also observed in children's understanding of germs, the associated illness threat and washing hands with soap as a prevention mechanism. The present study suggests that entertainment-education-based interventions have the potential to improve hygiene behavior among children while being low-cost.

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.

Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs.

METHODS

In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414.

FINDINGS

26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence.

INTERPRETATION

Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease.

FUNDING

Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.

Handwashing Practices and Associated Factors Among School Children in Kirkos and Akaki Kality Sub-Cities, Addis Ababa, Ethiopia

BACKGROUND

Provision of handwashing facilities and proper practices are essential for preventing fecal-oral and acute respiratory infectious diseases. The aim of this study was to assess availability of handwashing facilities and predictors to students' good hygiene practices in Addis Ababa, Ethiopia.

METHODS

A mixed-methods study design was conducted in schools of Addis Ababa from January to March 2020 in 384 students, 98 school directors, 6 health clubs, and 6 school administrators. Data were collected using pretested interviewer-administered questionnaires, interview guide, and observational checklists. The quantitative data were entered into EPI Info version 7.2.2.6 and analyzed using SPSS 22.0. A bivariable at P < .2 and multivariable logistic regression analysis at P < .05 for quantitative and thematic analysis for qualitative data were used.

RESULTS

Handwashing stations were available in 85 (86.7%) of the schools. However, 16 (16.3%) schools had neither water nor soap near the handwashing facilities while 33 (38.8%) of schools had both. There was no high school that had both soap and water. Approximately one-third (135, 35.2%) of students practiced proper handwashing, among which 89 (65.9%) were from private schools. The handwashing practices were significantly associated with gender (AOR = 2.45, 95% CI: (1.66-3.59)), having trained coordinator (AOR = 2.16, 95% CI: (1.32-2.48)) and health education program (AOR = 2.53, 95% CI: (1.73-3.59)), school ownership (AOR = 0.49, 95% CI: (0.33-0.72)), and training (AOR = 1.74, 95% CI: (1.82-3.69)). Water supply interruption, and lack of budget, adequate space, training, health education, maintenance, and coordination were the main barriers that prevent students from practicing proper handwashing.

CONCLUSIONS

Handwashing facilities and materials provision and good handwashing practices of students were low. Moreover, providing soap and water for handwashing was insufficient to promote good hygiene practices. There should be regular hygiene education, training, maintenance, and better coordination among stakeholders to create a healthy school environment.

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.

Spatial epidemiology of acute respiratory infections in children under 5 years and associated risk factors in India: District-level analysis of health, household, and environmental datasets

Background

In India, acute respiratory infections (ARIs) are a leading cause of mortality in children under 5 years. Mapping the hotspots of ARIs and the associated risk factors can help understand their association at the district level across India.

Methods

Data on ARIs in children under 5 years and household variables (unclean fuel, improved sanitation, mean maternal BMI, mean household size, mean number of children, median months of breastfeeding the children, percentage of poor households, diarrhea in children, low birth weight, tobacco use, and immunization status of children) were obtained from the National Family Health Survey-4. Surface and ground-monitored PM_2.5 and PM₁₀ datasets were collected from the Global Estimates and National Ambient Air Quality Monitoring Programme. Population density and illiteracy data were extracted from the Census of India. The geographic information system was used for mapping, and ARI hotspots were identified using the Getis-Ord Gi^* spatial statistic. The quasi-Poisson regression model was used to estimate the association between ARI and household, children, maternal, environmental, and demographic factors.

Results

Acute respiratory infections hotspots were predominantly seen in the north Indian states/UTs of Uttar Pradesh, Bihar, Delhi, Haryana, Punjab, and Chandigarh, and also in the border districts of Uttarakhand, Himachal Pradesh, and Jammu and Kashmir. There is a substantial overlap among PM_2.5, PM₁₀, population density, tobacco smoking, and unclean fuel use with hotspots of ARI. The quasi-Poisson regression analysis showed that PM_2.5, illiteracy levels, diarrhea in children, and maternal body mass index were associated with ARI.

Conclusion

To decrease ARI in children, urgent interventions are required to reduce the levels of PM_2.5 and PM₁₀ (major environmental pollutants) in the hotspot districts. Furthermore, improving sanitation, literacy levels, using clean cooking fuel, and curbing indoor smoking may minimize the risk of ARI in children.

Diarrhoea, malnutrition, and dehydration associated with school water, sanitation, and hygiene in Metro Manila, Philippines: A cross-sectional study

INTRODUCTION

Diarrhoea, malnutrition, and dehydration threaten the lives of millions of children globally due to inadequate water, sanitation, and hygiene (WaSH). Our study aimed to identify environmental and behavioural risk factors of these health outcomes among schoolchildren in Metro Manila, Philippines.

MATERIALS AND METHODS

We analysed data from a multistage cluster sample of schoolchildren in grades 5, 6, 7, 9, and 10 (ages ~10-15 years old) to investigate WaSH facilities and hygiene practices. Outcomes were: self-reported diarrhoea, measured via questionnaire; observed malnutrition (stunting, undernutrition [underweight/thin and wasted/severely thin], over-nutrition [overweight and obese]), measured via anthropometry; dehydration, measured via urine specific gravity/urine test strips. We used multiple logistic regression to explore correlates.

RESULTS

We included 1558 students from 15 schools in three cities. Over 28% (421) of students had diarrhoea and 68% (956) were dehydrated. Over 15% (227) of students were stunted, ~9% (127) were undernourished, and >21% (321) were over-nourished. Diarrhoea was associated with poor handwashing, while dehydration was associated with the lack of water in school restrooms. Stunting was linked with not using the school restroom, the lack of water in school restrooms, and the lack of hygiene lessons in school. Undernutrition was associated with the lack of a school restroom cleaning policy. Risks of diarrhoea, stunting, and undernutrition decreased as the number of school restrooms increased. Risks of stunting and overnutrition decreased as the numbers of school toilets increased. Having more than seven handwashing basins was associated with decreased risk of dehydration.

DISCUSSION

Findings from our cross-sectional study cannot describe causation. We have found associations that suggest that school restroom cleaning policies, adequate water supply, improved handwashing, and hygiene education are needed to prevent disease. School-based WaSH interventions are recommended to provide water in school WaSH facilities, promote handwashing, and improve hygiene-related knowledge.

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals.

Effects of a Water, Sanitation and Hygiene Mobile Health Program on Respiratory Illness in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program

Acute respiratory infections are a leading cause of morbidity and mortality among young children globally. The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on respiratory illness among diarrhea patients and their household members in urban Dhaka, Bangladesh. A cluster-randomized controlled trial of the CHoBI7 mHealth program was conducted among diarrhea patient households in Dhaka, Bangladesh. Patients were randomized to three arms: standard recommendation on oral rehydration solution use, health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages for 12 months) (no home visits), and health facility delivery of CHoBI7 plus two home visits and mHealth. Respiratory symptoms were assessed during monthly clinical surveillance over the 12-month surveillance period. Respiratory illness was defined as rapid breathing, difficulty breathing, wheezing, or coughing. Two thousand six hundred twenty-six participants in 769 households were randomly allocated to three arms: 849 participants to the standard message arm, 886 to the mHealth with no home visits arm, and 891 to the mHealth with two home visits arm. Compared with the standard message arm, participants in the mHealth with no home visits arm (Prevalence Ratio [PR]: 0.89 [95% CI: 0.80, 0.98]), and the mHealth with two home visits arm (PR: 0.89 [95% CI: 0.81, 0.99]) had significantly lower respiratory illness prevalence over the 12-month program period. Our findings demonstrate that the CHoBI7 mHealth program is effective in reducing respiratory illness among diarrhea patient households.

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

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

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Jean DT. COVID-19 & Sociocultural Determinants of Global Sanitation: An Aide-Mémoire and Call to Decolonize Global Sanitation Research & Practice

COVID-19 has highlighted and exacerbated many global health inequities. Emerging evidence suggests that SARS-CoV-2 can spread through fecal aerosols, making sanitation a critical part of the COVID-19 mitigation strategy and providing an opportunity to reflect on current challenges and opportunities related to global sanitation at large. Global sanitation interventions continue to fall short of their target expectations, leading to millions of deaths and illnesses worldwide. Eurocentric approaches to sanitation fail to account for sociocultural determinants of sanitation behaviors and health, leading to low sanitation intervention uptake. Global public health needs to take a decolonial approach to our research and practice, and meaningfully involve local communities to progress towards global health equity.

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.

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

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

Drinking Water Quality Mapping Using Water Quality Index and Geospatial Analysis in Primary Schools of Pakistan

Primary school children in the developing world often lack potable water, which may result in a high burden of water-related diseases and poor school performance. The present study aimed to characterize the drinking water quality in primary schools of Pakistan. We used a multistage random-sampling method to select 425 primary schools from selected districts of Sindh province. Standard methods were used to characterize water quality. The results were compared with maximum acceptable values recommended by the Pakistani National Environmental Quality Standards (Pak NEQS) and the World Health Organization (WHO) drinking water quality standards. Groundwater (62%) and surface water (38%) were identified as two major drinking water sources in the selected schools with varying levels of water quality. Among all parameters, dissolved oxygen (DO), pH, and nitrate remained within WHO and Pak NEQS water quality standard limit, while total dissolved solids (TDS) (33%), electrical conductivity (EC) (46%), chloride (34%), turbidity (27%), and hardness (11%) samples exceeded standard limits. All dissolved salts had moderate to strong positive correlations with TDS and EC values. Based on a water quality index (WQI), 74% of primary schools had access to excellent or good quality drinking water compared to 26% of schools that had access to either poor, very poor or unsuitable drinking water. Among all three regions, more schools from South Sindh had either poor, very poor or unsuitable drinking water (33%) compared to the Central (25%) and North zones (15%). Hence, water from these locations is unfit for human consumption and these schools need better water quality management plans to stop the spread of water-related diseases in primary school children.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Open defecation-free slippage and its associated factors in Ethiopia: a systematic review

BACKGROUND

Recent studies have shown an increase in open defecation and slippage of open defecation-free certified villages in Ethiopia, despite significant progress the country made on sanitation programs. Hence, realizing of existing facts, this study was conducted aiming at a critical review of available literature and to provide consolidated data showing the level of slippage and its associated factors in Ethiopia.

METHODS

Systematic literature searches were performed from four international databases. The search involved articles published from December 1, 2013, up to June 4, 2019. The Cochran's Q and I² test statistics were used to check heterogeneity among the studies. To negotiate heterogeneity from qualitative data, we used a mixed-method approach. The researchers also conducted a publication bias assessment and sensitivity analysis. A random effect meta-analysis was employed to determine the pooled estimates of open defecation free slippage rate with a 95% confidence interval (CI). The data analysis was performed using the CMA V.3 software program.

RESULT

After screening 1382 studies, 12 studies were finally included in this systematic review. The estimated pooled rate of open defecation-free slippage in Ethiopia was 15.9% (95% CI 12.9-19.4%). The main contributing factors for open defecation-free slippage were lack of technical support, financial constraints, low-quality building materials, improper program implementation, and lack of sanitation marketing.

CONCLUSION

It was estimated that 1 out of 6 Ethiopian households engaged in open defecation after they have certified open defecation-free status, implying the low possibility of achieving sustainable development goals of 2030, which aims to ensure sanitation for all. Therefore, the government of Ethiopia and donors should better give special attention to the following options: (1) awareness for open defecation-free slippage, (2) launch a post-open defecation-free program, and (3) encourage research on pro-poor sustainable sanitation technologies.

Effect of Improved Water Quality, Sanitation, Hygiene and Nutrition Interventions on Respiratory Illness in Young Children in Rural Bangladesh: A Multi-Arm Cluster-Randomized Controlled Trial

Acute respiratory infections cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory illness was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, P: 8.9%), caregivers of index children reported significantly lower ARI in the water (P: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (P: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (P: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (P: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (P: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (P: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.

Burden of enterotoxigenic Escherichia coli and shigella non-fatal diarrhoeal infections in 79 low-income and lower middle-income countries: a modelling analysis

Background

Enterotoxigenic Escherichia coli (ETEC) and shigella are two major pathogens that cause moderate-to-severe diarrhoea in children younger than 5 years. Diarrhoea is associated with an increased risk of stunting, which puts children at risk of death due to other infectious diseases.

Methods

We modelled ETEC-related and shigella-related mortality and the effect of moderate-to-severe diarrhoea episodes to determine the number of children with stunting due to these infections in 79 low-income and lower middle-income countries. We applied population attributable risk for increased number of deaths due to other infectious diseases in children who are stunted. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings

In children younger than 5 years, we estimate 196 million (95% UI 135–269) episodes of ETEC and shigella diarrhoea occur annually, resulting in 3·5 million (0·8–5·4) cases of moderate-to-severe stunting and 44 400 (29 400–59 800) total ETEC deaths and 63 100 (44 000–81 900) total shigella deaths in 2015. Additional infectious disease mortality due to stunting resulted in increases of 24% (8–34; for ETEC) and 28% (10–39; for shigella) over direct deaths due to diarrhoeal episodes. The distribution of mortality and morbidity varied geographically, with African Region and Eastern Mediterranean Region countries bearing the greatest burden.

Interpretation

The expanded effects of non-fatal ETEC and shigella-related diarrhoeal episodes can have lasting consequences. Prevention of these infections could reduce the risk of direct death and stunting and deaths due to other infectious diseases. Understanding the countries and populations with the highest disease risk helps to target interventions for the most vulnerable populations.

Funding

The Bill & Melinda Gates Foundation.

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid–upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77–0.99], but no effect in the combined WSHN group weakens this finding.

Impact of school-based malaria case management on school attendance, health and education outcomes: a cluster randomised trial in southern Malawi

Introduction

Evidence indicates children who suffer from ill-health are less likely to attend or complete schooling. Malaria is an important cause of morbidity and mortality in school-age children. However, they are less likely to receive malaria treatment at health facilities and evidence for how to improve schoolchildren's access to care is limited. This study aimed to evaluate the impact of a programme of school-based malaria case management on schoolchildren's attendance, health and education.

Methods

A cluster randomised controlled trial was conducted in 58 primary schools in Zomba District, Malawi, 2011-2015. The intervention, implemented in 29 randomly selected schools, provided malaria rapid diagnostic tests and artemisinin-based combination therapy to diagnose and treat uncomplicated malaria as part of basic first aid kits known as 'Learner Treatment Kits' (LTK). The primary outcome was school attendance, assessed through teacher-recorded daily attendance registers and independent periodic attendance spot checks. Secondary outcomes included prevalence of Plasmodium spp infection, anaemia, educational performance, self-reported child well-being and health-seeking behaviour. A total of 9571 children from standards 1-7 were randomly selected for assessment of school attendance, with subsamples assessed for the secondary outcomes.

Results

Between November 2013 and March 2015, 97 trained teachers in 29 schools provided 32 685 unique consultations. Female schoolchildren were significantly more likely than male to seek a consultation (unadjusted OR=1.78 (95% CI 1.58 to 2.00). No significant intervention effect was observed on the proportion of child-days recorded as absent in teacher registers (n=9017 OR=0.90 (95% CI 0.77 to 1.05), p=0.173) or of children absent during random school visits-spot checks (n=5791 OR=1.09 (95% CI 0.87 to 1.36), p=0.474). There was no significant impact on child-reported well-being, prevalence of Plasmodium spp, anaemia or education scores.

Conclusion

Despite high community demand, the LTK programme did not reduce schoolchildren's absenteeism or improve health or education outcomes in this study setting.

Trial registration number

ClinicalTrials.gov NCT02213211.

Does Basic Sanitation Prevent Diarrhea? Contextualizing Recent Intervention Trials through a Historical Lens

Three of four recent major sanitation intervention trials found no effect on diarrhea. These results conflicted with longstanding beliefs from decades of literature. To understand this discordance, we placed recent trials into the historical context that preceded them in two ways. First, we evaluated the history of published literature reviews on sanitation and diarrhea. Second, we conducted meta-analyses on studies from the most recent systematic review to uncover features that predict effectiveness. We found that 13 literature reviews dating to 1983 consistently estimated a significant protective effect of sanitation against diarrhea. However, these were marred by flawed studies and inappropriately averaged effects across widely heterogeneous interventions and contexts. Our meta-analyses highlight that the overall effect of sanitation on diarrhea was largely driven by sewerage and interventions that improved more than sanitation alone. There is no true overall effect of sanitation because variability between intervention types and implementation contexts is too complex to average. Ultimately, the null effects of recent latrine interventions are not surprising. Instead, the one trial that found a strong relative reduction in diarrhea is the historical outlier. The development of transformative sanitation interventions requires a better understanding of the social and environmental contexts that determine intervention effectiveness.

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

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

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Impact of a school-based water, sanitation, and hygiene intervention on school absence, diarrhea, respiratory infection, and soil-transmitted helminths: results from the WASH HELPS cluster-randomized trial

Background

Water, sanitation, and hygiene (WASH) in schools is promoted by development agencies as a modality to improve school attendance by reducing illness. Despite biological plausibility, the few rigorous studies that have assessed the effect of WASH in schools (WinS) interventions on pupil health and school attendance have reported mixed impacts. We evaluated the impact of the Laos Basic Education, Water, Sanitation and Hygiene Programme – a comprehensive WinS project implemented by UNICEF Lao People’s Democratic Republic (Lao PDR) in 492 primary schools nationwide between 2013 and 2017 – on pupil education and health.

Methods

From 2014-2017, we conducted a cluster-randomized trial among 100 randomly selected primary schools lacking functional WASH facilities in Saravane Province, Lao PDR. Schools were randomly assigned to either the intervention (n = 50) or comparison (n = 50) arm. Intervention schools received a school water supply, sanitation facilities, handwashing facilities, drinking water filters, and behavior change education and promotion. Comparison schools received the intervention after research activities ended. At unannounced visits every six to eight weeks, enumerators recorded pupils’ roll-call absence, enrollment, attrition, progression to the next grade, and reported illness (diarrhea, respiratory infection, conjunctivitis), and conducted structured observations to measure intervention fidelity and adherence. Stool samples were collected annually prior to de-worming and analyzed for soil-transmitted helminth (STH) infection. In addition to our primary intention-to-treat analysis, we conducted secondary analyses to quantify the role of intervention fidelity and adherence on project impacts.

Results

We found no impact of the WinS intervention on any primary (pupil absence) or secondary (enrollment, dropout, grade progression, diarrhea, respiratory infection, conjunctivitis, STH infection) impacts. Even among schools with the highest levels of fidelity and adherence, impact of the intervention on absence and health was minimal.

Conclusions

While WinS may create an important enabling environment, WinS interventions alone and as currently delivered may not be sufficient to independently impact pupil education and health. Our results are consistent with other recent evaluations of WinS projects showing limited or mixed effects of WinS.

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

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

The Effect of Therapeutic Clowning on Handwashing Technique and Microbial Colonization in Preschool Children

PURPOSE

This study aimed to determine the effect of therapeutic clowning on handwashing technique and microbial colonization in preschool children.

DESIGN

This randomized controlled trial was conducted using pre-test and post-test experimental and control groups.

METHODS

The study was conducted between March and June 2016 in two kindergartens in eastern Turkey. The study was completed with a total of 195 students, including 90 students in the experimental group and 105 students in the control group. A questionnaire was used for data collection. This questionnaire included sections about the subjects' descriptive characteristics and the results of the bacterial cultures of their hand swabs. For the collection of these swabs, the subjects were informed in advance, and samples were collected at predetermined times. The swabs were analyzed to determine the bacterial colonization of the subjects' hands. Clowns and video activities were used as intervention tools in the study.

FINDINGS

In the post-test, the microbial growth was ≤10³ in 68.9% and >10³ in 31.1% of the subjects in the experimental group. In contrast, the growth was ≤10³ in 34.3% and >10³ in 65.7% of the control group subjects. The difference in the post-test microbial growths of the two groups was statistically significant (p < .000).

CONCLUSIONS

The hygienic handwashing technique taught in the therapeutic clowning and videos reduced the bacterial colonization on the preschool children's hands by 50%. Moreover, this method was effective in reducing the growth rate of coliform bacteria that indicate undesirable, poor hygiene of the hands.

CLINICAL RELEVANCE

Considering these results, we recommend that pediatric healthcare professionals use entertaining methods such as those involving clowns to teach and guide children regarding hygienic handwashing techniques.

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

Background

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

Methodology/Principal findings

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

Conclusions/Significance

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

Trial registration

The trial was registered at ClinicalTrials.gov (NCT01787058)

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

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

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

Detection of Immunoglobulin G Antibodies to Taenia solium Cysticercosis Antigen Glutathione-S-Transferase-rT24H in Malian Children Using Multiplex Bead Assay

Blood samples from 805 students attending 42 elementary schools in Mopti, Sikasso, and Koulikoro regions, and Bamako district in Mali participated in a school water, sanitation, and hygiene intervention. Immunoglobulin (Ig) G responses to several antigens/pathogens were assessed by a multiplex bead assay (MBA), and the recombinant Taenia solium T24H antigen was included. Of all students tested, 8.0% were positive to rT24H, but in some schools 25-30%. A cluster of 12 widespread school locations showed not only a relative risk of 3.23 for T. solium exposure and significantly higher IgG responses (P < 0.001) but also significantly lower elevation (P = 0.04) (m, above sea level) compared with schools outside the cluster. All schools at elevations < 425 m showed significantly higher IgG responses (P = 0.017) than schools at elevations ≥ 425 m. The MBA is an excellent serological platform that provides cost-effective opportunities to expand testing in serosurveys.

Effect of an integrated intervention package of preventive chemotherapy, community-led total sanitation and health education on the prevalence of helminth and intestinal protozoa infections in Côte d'Ivoire

Background

Preventive chemotherapy with donated anthelminthic drugs is the cornerstone for the control of helminthiases. However, reinfection can occur rapidly in the absence of clean water and sanitation coupled with unhygienic behaviour. The purpose of this study was to assess the effect of an integrated package of interventions, consisting of preventive chemotherapy, community-led total sanitation (CLTS) and health education, on the prevalence of helminth and intestinal protozoa infections and on participants’ knowledge, attitude, practice and beliefs (KAPB) towards these diseases including water, sanitation and hygiene (WASH).

Methods

A cross-sectional survey was carried out in nine communities of south-central Côte d’Ivoire to assess people’s infection with helminths and intestinal protozoa and KAPB. Subsequently, interventions were targeted to five communities, while the remaining communities served as control. The intervention encouraged latrine construction and an evaluation was done 6–7 months later to determine open defecation status of the respective communities. Anthelminthic treatment was provided to all community members. A follow-up cross-sectional survey was conducted approximately one year later, using the same procedures.

Results

Overall, 810 people had complete baseline and follow-up data and were given anthelminthic treatment. The baseline prevalence of hookworm, Schistosoma haematobium, Trichuris trichiura, Schistosoma mansoni and Ascaris lumbricoides was 31.1%, 7.0%, 2.0%, 1.0% and 0.3%, respectively. Four of the five intervention communities were classified open-defecation free. For hookworm infection, we observed higher negative changes in terms of proportion of decrease (-0.10; 95% confidence interval (CI): - 0.16, -0.04) and higher egg reduction rate (64.9 vs 15.2%) when comparing intervention with control communities. For intestinal protozoa, prevalence reduction was higher in intervention compared to control communities (8.2 vs 2.6%) and WASH indicators and intervention outcomes associated with lower odds for infection at follow-up. The intervention significantly impacted on reported latrine use (before: 15.5%, after: 94.6%), open defecation in the community surroundings (before: 75.0%, after: 16.7%) and awareness for environmental contamination through open defecation (before: 20.4%, after: 52.2%).

Conclusions

An integrated package of interventions consisting of preventive chemotherapy, health education and CLTS reduces the prevalence of helminth and intestinal protozoa infection. Additional studies in other social-ecological settings are warranted to confirm our findings.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2642-x) contains supplementary material, which is available to authorized users.

Small scale migration along the interoceanic highway in Madre de Dios, Peru: an exploration of community perceptions and dynamics due to migration

Background

Madre de Dios, a southern state in the Peruvian Amazon basin, has experienced rapid development as well as an influx of migrants since the construction of the Interoceanic Highway (IOH) connecting Brazil, Bolivia, and the Peruvian coast. We explored perceptions of migration and development in up to eight communities along the IOH in Madre de Dios following construction of the highway.

Methods

We conducted a multiple methods study involving focus group (FG) discussions and interviews with key informants (KIs) in eight communities in Madre de Dios. The data was used to develop and apply a survey on demographics, financial, personal, social, human, and physical capital in four communities between February 2014 and March 2015.

Results

We conducted 12 FGs and 34 KI interviews. A total of 522 people participated in the survey. Comparing migrants (those who had moved to the area after construction of the IOH) and non-migrants, we found no difference in food security or access to health services. The majority (67.6%) of respondents from both groups reported that illness was their primary threat to well-being. Non-migrants owned more land than migrants (p < 0.001), were more likely to have piped water directly in their home (p = 0.046), and were more likely to participate in community groups (p = 0.012). Looking at perceptions about migrants, KIs and FGs discussed both positive perceptions of migrants (increased cultural exchange and new technology) and negative perceptions (increased drugs and alcohol in their communities and a lack of investment in the community). Both migrants and non-migrants reported trusting the local government more than the national government.

Conclusions

Although we hypothesized that migrants would have decreased access to food, water, health services, and land relative to non-migrants, our results show that the only significant differences were in land ownership and water access. Efforts to improve community infrastructure should be carried out at the local level and focus on improving issues reported by both groups, such as potable water, sewage, and increased access to health services. Furthermore, an emphasis on community cohesion, ensuring land rights, and increasing long-term job opportunities should help ease tensions between migrants and non-migrants.

Electronic supplementary material

The online version of this article (10.1186/s12914-018-0152-8) contains supplementary material, which is available to authorized users.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

Evaluation of Immunoglobulin G Responses to Plasmodium falciparum and Plasmodium vivax in Malian School Children Using Multiplex Bead Assay

Malaria serology through assaying for IgG against Plasmodium spp. antigens provides evidence into the infection history for an individual. The multiplex bead assay (MBA) allows for detection of IgG against multiple Plasmodium spp., and can be especially useful in many regions where Plasmodium falciparum is of primary clinical focus, but other species are co-endemic. Dried blood spots were collected from 805 Malian children attending 42 elementary schools in the regions of Mopti, Sikasso, Koulikoro, and Bamako capital district, and IgG assayed by MBA. As southern Mali is known to be holoendemic for P. falciparum, merozoite surface protein 1 19-kDa subunit (MSP-1₄₂) and apical membrane antigen 1 (AMA-1) antigens were included for serology against this parasite. Responses to these antigens both provided high estimates for lifetime exposure, with 730 (90%) children with IgG antibodies for MSP-1₄₂, 737 (91%) for AMA-1, and 773 (96%) positive for either or both. Also included was the antigen Plasmodium vivax MSP-1₁₉, against which 140 (17.4%) children were found to have antibodies. Increases in antibody titers with older age were clearly seen with the P. falciparum antigens, but not with the P. vivax antigen, likely indicating more of a sporadic, rather than sustained transmission for this species. The MBA provides effective opportunities to evaluate malaria transmission through serological analysis for multiple Plasmodium species.

Serological Responses to Filarial Antigens in Malian Children Attending Elementary Schools

Dried blood spots (DBS) were collected from 805 children attending 42 elementary schools in the regions of Mopti, Sikasso, Koulikoro, and the regional capital of Bamako in Mali as part of an evaluation of a school health intervention. Eluted immunoglobulin (Ig) G from the DBS was assessed by a multiplex bead assay (MBA) for two filariasis antigens, Wuchereria bancrofti, Wb123, and Brugia malayi, Bm14, to determine the effectiveness of mass drug administration (MDA) programs to eliminate lymphatic filariasis (LF). The prevalence of positive IgG responses in the children to each antigen was less than 1%, indicating effectiveness of the MDA against LF. The MBA is an excellent serological platform that provides cost-effective opportunities to evaluate public health activities beyond the survey targets.

The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis

BACKGROUND

An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health.

METHODS AND FINDINGS

We systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use.

CONCLUSIONS

Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.

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

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