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Wang X, Liu J, Wu Y, Su B, Chen M, Ma Q, Ma T, Chen L, Zhang Y, Dong Y, Song Y, Ma J. Enhancing the effectiveness of infectious disease health education for children and adolescents in China: a national multicenter school-based trial. BMC Public Health 2023; 23:1161. [PMID: 37322442 PMCID: PMC10273566 DOI: 10.1186/s12889-023-16000-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/27/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Infectious diseases pose a significant risk to the health and well-being of children and adolescents, and can even be life-threatening. Thus, our study aimed to explore the effectiveness of health education based on the social-ecological model in improving the knowledge of infectious diseases among this vulnerable population. METHODS This study was a school-based intervention conducted in seven Chinese provinces in 2013, involving a total of 26,591 children and adolescents in the intervention group and 24,327 in the control group. The intervention group received a comprehensive health intervention based on the social-ecological model (SEM) over six months, which included a supportive environment, health education on infectious diseases, guidance on self-monitoring infectious disease-related behaviors, and other measures. Data on infectious disease-related knowledge and other characteristics were collected through questionnaires. The main outcome measure will be the difference in the effectiveness of health education regarding infectious diseases in children and adolescents between baseline and post-intervention. A mixed-effects regression model was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) to assess the impact of infectious disease-related interventions on the participants. RESULTS We utilized a socioecological model as the foundation for a six-month health education program on infectious diseases targeting children and adolescents in the intervention group. At the individual and community levels, the correct rate of health behavior related to infectious diseases in the intervention group was higher than that in the control group (P < 0.05), the ORs (95% CI) were 0.94 (0.90-0.99) and 0.94 (0.89-0.99), respectively. But the intervention effect was not significant at the interpersonal level. The intervention effect at the organizational level was obvious, with an increase in opportunities for children and adolescents to acquire knowledge of infectious diseases from courses and lectures, teachers, and doctors, (all P < 0.05), with the ORs (95% CI) of 0.92 (0.87-0.97) and 0.86 (0.83-0.94), respectively. However, there was no significant difference between the intervention group and the control group in school infectious disease health education policy. CONCLUSION Enhancing health education regarding infectious diseases is crucial in promoting comprehensive prevention and control measures among children and adolescents. Nevertheless, it remains imperative to reinforce health education on infectious diseases at the interpersonal and policy levels. This holds significant reference value for mitigating childhood infectious diseases in the post-COVID-19 era.
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Affiliation(s)
- Xinxin Wang
- School of Public Health, Ningxia Medical University, Yinchuan, China
- Key Laboratory of Environmental Factors and Chronic Release Control, Yinchuan, China
| | - Jieyu Liu
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Yu Wu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences / Peking Union Medical College, Beijing, China
| | - Binbin Su
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences / Peking Union Medical College, Beijing, China
| | - Manman Chen
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Qi Ma
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Tao Ma
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Li Chen
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Yi Zhang
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
| | - Yanhui Dong
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China.
| | - Yi Song
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China.
| | - Jun Ma
- Institute of Child and Adolescent Health, School of Public Health, National Health Commission Key Laboratory of Reproductive Health, Peking University, Beijing, 100191, China
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Buitrago-García T, Sawadogo NH, Souares A, Koulidiati JL, Sié A, Bärnighausen T, Langlotz S, McMahon SA. Female-friendly toilets in schools in Burkina Faso: A mixed-methods study using photo-elicitation. J Glob Health 2022; 12:04057. [PMID: 36073661 PMCID: PMC9454237 DOI: 10.7189/jogh.12.04057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background An absence of gender-sensitive sanitation facilities in schools and the negative effects this has on girls has been widely discussed among advocacy groups, though less examined in academic spheres. Drawing on triangulated data, we outline current challenges and respondent-driven solutions to enhance the female-friendly nature of toilets in a context of extreme poverty. Methods This mixed-methods study was informed by the tenets of human-centred design. We first quantitatively assessed facilities in 14 secondary schools in the Kossi Province of Burkina Faso. We then collected qualitative data, including 15 focus group discussions and 53 in-depth interviews among schoolgirls, mothers, teachers and key informants. We applied photo-elicitation, a novel method, to explore perceptions of facilities and the desirability and feasibility of interventions to improve gender-friendly sanitation facilities. Results No school met international water, sanitation and hygiene (WASH) standards for schools. Roughly one third of schools did not have water and, when present, there was no reliable way to use it within the toilet complex. Schoolgirls shared feelings of shame and stress when menstruating at school, and said that they would avoid using school toilets, if possible. Schoolgirls described water access as the most urgent need to address, followed by fostering privacy and facilitating cleanliness within facilities. Mothers and teachers mostly aligned with these priorities, while key informants additionally emphasised the need to raise awareness on both general and menstrual hygiene and to develop maintenance systems. Photo-elicitation engaged and empowered participants to pinpoint priorities and concrete solutions, namely a need for doors and locks, water containers and cleaning materials. Conclusions WASH needs in many schools remain unmet. Women and girls should be involved in decision-making across stages of intervention design and implementation. Young women's voices merit greater inclusion in academic literature. Future interventions should enhance access to water and privacy. Future research could explore maintenance and monitoring strategies to develop guidance on sustainable solutions.
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Affiliation(s)
- Teresa Buitrago-García
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.,La Paz University Hospital, Madrid, Spain
| | | | - Aurélia Souares
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Sié
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.,Nouna Health Research Centre, Nouna, Burkina Faso
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.,Africa Health Research Institute, Nelson R. Mandela Medical School, Umbilo, Durban, South Africa.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah Langlotz
- Chair of Development Economics (Prof. Fuchs), Georg-August-Universität Göttingen, Göttingen, Germany
| | - Shannon A McMahon
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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Morgan CE, Bowling JM, Bartram J, Kayser GL. Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda. Int J Hyg Environ Health 2021; 236:113804. [PMID: 34242999 PMCID: PMC8363166 DOI: 10.1016/j.ijheh.2021.113804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Camille E Morgan
- The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - J Michael Bowling
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Jamie Bartram
- The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Georgia L Kayser
- The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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SACKOU KOUAKOU JULIEGHISLAINE, DESQUITH ANGELEAKA, BARRO-KIKI PULCHERIECHRISTIANEMARIE, KOUAME JEROME, TIADE MARIELAURE, GOKPEYA MARIETTEBEDIAKON, KOUADIO LUCKOUAKOU. Personal hygiene in schools: retrospective survey in the northern part of Côte d'Ivoire. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2021; 62:E75-E81. [PMID: 34322620 PMCID: PMC8283648 DOI: 10.15167/2421-4248/jpmh2021.62.1.1655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 03/03/2021] [Indexed: 11/16/2022]
Abstract
Introduction Students' personal hygiene helps maintain health and promote good academic performance. When health facilities are insufficient, this hygiene can be difficult to achieve. We wanted to analyse the determinants of personal hygiene in schools in the northern region of Côte d'Ivoire. Methods The retrospective cross-sectional study brings together data on 2,035 schoolchildren recruited from thirty schools in northern Côte d'Ivoire. Indexes on personal hygiene were constructed and analysed in comparison to the socio-demographic characteristics of students, homes and schools. They were analysed with R Software version 1.1.463, the χ2 test and a logistic regression model. Results Overall, the majority of students had good personal hygiene (82.75%) with an average personal hygiene score of 4.74 ± 1.36. The predictors of good personal hygiene among schoolchildren were female gender (OR = 1.5; 95% CI = 4.31-16.37), father's primary education level (OR = 1.55; 95% CI = 1.07-2.29), the father's income level above 60,000 FCFA (90 Euros) and modern housing (OR = 1.45; 95% CI = 1.05-2.03). However, the poor level of home sanitation resulted in poor personal hygiene among the students (OR = 0.34; 95% CI = 0.23-0.5). Conclusions Measures to raise the standard of living of families and the provision of sanitary facilities in homes becomes necessary in order to improve students personal hygiene.
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Affiliation(s)
| | - ANGELE AKA DESQUITH
- Correspondence: Angele Aka Desquith, Logistics Department, Expanded Programme on Immunization, 18 BP 976 Abidjan 18, Côte d’Ivoire - Tel.: +2250707812934 - E-mail:
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Drinking Water Quality Mapping Using Water Quality Index and Geospatial Analysis in Primary Schools of Pakistan. WATER 2020. [DOI: 10.3390/w12123382] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Duijster D, Buxton H, Benzian H, Dimaisip-Nabuab J, Monse B, Volgenant C, Dreibelbis R. Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial. Int J Public Health 2020; 65:1699-1709. [PMID: 33141327 PMCID: PMC7717050 DOI: 10.1007/s00038-020-01514-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/17/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Denise Duijster
- Department of Social Dentistry, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Helen Buxton
- Disease Control Department, School of Hygiene and Tropical Medicine London, London, UK
| | - Habib Benzian
- Department of Epidemiology and Health Promotion, WHO Collaborating Center for Quality Improvement and Evidence-based Dentistry, College of Dentistry, New York University, New York, USA
| | - Jed Dimaisip-Nabuab
- Gesellschaft für Internationale Zusammenarbeit (GIZ), Metro Manila, Philippines
| | - Bella Monse
- Gesellschaft für Internationale Zusammenarbeit (GIZ), Metro Manila, Philippines
| | - Catherine Volgenant
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Robert Dreibelbis
- Disease Control Department, School of Hygiene and Tropical Medicine London, London, UK
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Ahmed J, Wong LP, Chua YP, Channa N, Mahar RB, Yasmin A, VanDerslice JA, Garn JV. Quantitative Microbial Risk Assessment of Drinking Water Quality to Predict the Risk of Waterborne Diseases in Primary-School Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082774. [PMID: 32316585 PMCID: PMC7215448 DOI: 10.3390/ijerph17082774] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 01/13/2023]
Abstract
Primary-school children in low- and middle-income countries are often deprived of microbiologically safe water and sanitation, often resulting in a high prevalence of gastrointestinal diseases and poor school performance. We used Quantitative Microbial Risk Assessment (QMRA) to predict the probability of infection in schoolchildren due to consumption of unsafe school water. A multistage random-sampling technique was used to randomly select 425 primary schools from ten districts of Sindh, Pakistan, to produce a representative sample of the province. We characterized water supplies in selected schools. Microbiological testing of water resulted in inputs for the QMRA model, to estimate the risks of infections to schoolchildren. Groundwater (62%) and surface water (38%) were identified as two major sources of drinking water in the selected schools, presenting varying degrees of health risks. Around half of the drinking-water samples were contaminated with Escherichia coli (49%), Shigella spp. (63%), Salmonella spp. (53%), and Vibrio cholerae (49%). Southern Sindh was found to have the highest risk of infection and illness from Campylobacter and Rotavirus. Central and Northern Sindh had a comparatively lower risk of waterborne diseases. Schoolchildren of Karachi were estimated to have the highest probability of illness per year, due to Campylobacter (70%) and Rotavirus (22.6%). Pearson correlation was run to assess the relationship between selected pathogens. V. cholerae was correlated with Salmonella spp., Campylobacter, Rotavirus, and Salmonella spp. Overall, the risk of illness due to the bacterial infection (E. coli, Salmonella spp., V. cholerae, Shigella, and Campylobacter) was high. There is a dire need for management plans in the schools of Sindh, to halt the progression of waterborne diseases in school-going children.
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Affiliation(s)
- Jamil Ahmed
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
- US- Pakistan Center for Advanced Studies in Water, Mehran University of Engineering & Technology, Jamhsoro 76062, Pakistan; (N.C.); (R.B.M.)
- Correspondence: (J.A.); (L.P.W.)
| | - Li Ping Wong
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
- Correspondence: (J.A.); (L.P.W.)
| | - Yan Piaw Chua
- Institute of Educational Leadership, Level 11, Wisma R & D, UM, University of Malaya, Jalan Pantai Baru, Kuala Lumpur 59000, Malaysia;
| | - Najeebullah Channa
- US- Pakistan Center for Advanced Studies in Water, Mehran University of Engineering & Technology, Jamhsoro 76062, Pakistan; (N.C.); (R.B.M.)
| | - Rasool Bux Mahar
- US- Pakistan Center for Advanced Studies in Water, Mehran University of Engineering & Technology, Jamhsoro 76062, Pakistan; (N.C.); (R.B.M.)
| | - Aneela Yasmin
- Department of Biotechnology, Sindh Agriculture University, Tandojam 70060, Sindh, Pakistan;
| | - James A. VanDerslice
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84112, USA;
| | - Joshua V. Garn
- School of Community Health Sciences, University of Nevada, Reno, NV 89557, USA;
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Buxton H, Dimaisip-Nabuab J, Duijster D, Monse B, Benzian H, Dreibelbis R. The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial. BMC Public Health 2019; 19:1680. [PMID: 31842809 PMCID: PMC6916048 DOI: 10.1186/s12889-019-7833-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 10/22/2019] [Indexed: 11/24/2022] Open
Abstract
Background Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level. Methods In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level. Results 20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality – between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035). Conclusion Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure. Trial registration ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.
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Affiliation(s)
- Helen Buxton
- Disease Control Department, London School of Hygiene and Tropical Medicine, Kepple Street, London, UK
| | - Jed Dimaisip-Nabuab
- Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines, 625 Pedro Gil St, Ermita, 1000, Manila, Metro Manila, Philippines
| | - Denise Duijster
- Department of Social Dentistry, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Gustav Mahlerlaan 3004, 1081LA, Amsterdam, The Netherlands
| | - Bella Monse
- Regional Fit for School Programme, Gesellschaft für Internationale Zusammenarbeit (GIZ), L.P. Leviste corner Rufino Street, Makati City, Metro Manila, Philippines
| | - Habib Benzian
- Department of Epidemiology and Health Promotion, WHO Collaborating Center for Quality Improvement and Evidence-based Dentistry, College of Dentistry & College of Global Public Health, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, Kepple Street, London, UK.
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Okello E, Kapiga S, Grosskurth H, Makata K, Mcharo O, Kinungh'i S, Dreibelbis R. Factors perceived to facilitate or hinder handwashing among primary students: a qualitative assessment of the Mikono Safi intervention schools in NW Tanzania. BMJ Open 2019; 9:e030947. [PMID: 31784435 PMCID: PMC6924754 DOI: 10.1136/bmjopen-2019-030947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/26/2019] [Accepted: 11/05/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To qualitatively assess the effects of a multi-modal school-based water, sanitation and hygiene (WASH) intervention on handwashing behaviour among primary students in North Western (NW) Tanzania. DESIGN The study was a qualitative assessment of barriers and facilitators to handwashing among students attending primary schools participating in the Mikono Safi Trial (Kiswahili for 'Clean Hands), a cluster-randomised trial assessing the impact of a school-based WASH intervention on selected soil transmitted helminth infections. Data collection methods included in-depth interviews with teachers, focus group discussions and friendship pair interviews with students collected between April and October 2018. The Capability-Opportunity-Motivation and Behaviour model was used to inform data collection and analysis. SETTING The study was conducted in four purposively selected intervention schools in three districts of Kagera region, NW Tanzania (Bukoba urban, Bukoba rural and Muleba districts). PARTICIPANTS Participants comprised 16 purposively selected teachers aged between 23 and 52 years and 100 students aged 7-15 years RESULTS: The Mikono Safi intervention increased students' reported capability and motivation to wash their hands with soap at key times, particularly after visiting the toilet. Improvements in students' handwashing knowledge and skills were reported by both teachers and students, and motivation for handwashing was enhanced by emotional drivers such as disgust, fear and nurture. Newly established handwashing stations improved the physical opportunity to wash hands, although the availability of water and the provision of soap was not always consistent (eg, due to internal organisational shortcomings or during the dry season). Students and teachers were actively engaged in intervention implementation which created a school community that valued and supported improved hand hygiene. CONCLUSION The intervention was successful in improving capability and motivation for handwashing. Handwashing opportunity was also greatly improved, although the supply with water and soap was sometimes interrupted, calling for much stronger multi-sectoral collaboration to improve access to water at schools. TRIAL REGISTRATION NUMBER ISRCTN45013173; Pre-results.
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Affiliation(s)
- Elialilia Okello
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Heiner Grosskurth
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Kenneth Makata
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
| | - Onike Mcharo
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
| | - Safari Kinungh'i
- National Institute for Medical Research (NIMR), Mwanza Centre, Mwanza, Tanzania
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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The Impact of a School-Based Water, Sanitation and Hygiene Intervention on Knowledge, Practices, and Diarrhoea Rates in the Philippines. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16214056. [PMID: 31652683 PMCID: PMC6861971 DOI: 10.3390/ijerph16214056] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/09/2019] [Accepted: 10/18/2019] [Indexed: 01/06/2023]
Abstract
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.
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Chard AN, Garn JV, Chang HH, Clasen T, Freeman MC. 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. J Glob Health 2019; 9:020402. [PMID: 31360445 PMCID: PMC6657003 DOI: 10.7189/jogh.09.020402] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Anna N Chard
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Joshua V Garn
- School of Community Health Sciences, University of Nevada Reno, Reno, Nevada, USA
| | - Howard H Chang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Delea MG, Snyder JS, Belew M, Caruso BA, Garn JV, Sclar GD, Woreta M, Zewudie K, Gebremariam A, Freeman MC. Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol. BMC Public Health 2019; 19:801. [PMID: 31226957 PMCID: PMC6588862 DOI: 10.1186/s12889-019-7040-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022] Open
Abstract
Background Unimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia. Methods Together with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes. Discussion While CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017. Electronic supplementary material The online version of this article (10.1186/s12889-019-7040-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maryann G Delea
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jedidiah S Snyder
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Bethany A Caruso
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joshua V Garn
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Gloria D Sclar
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mulat Woreta
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
| | | | | | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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McMichael C. Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16030359. [PMID: 30696023 PMCID: PMC6388361 DOI: 10.3390/ijerph16030359] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Celia McMichael
- School of Geography, The University of Melbourne, Carlton 3053, Australia.
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Chard AN, Trinies V, Moss DM, Chang HH, Doumbia S, Lammie PJ, Freeman MC. The impact of school water, sanitation, and hygiene improvements on infectious disease using serum antibody detection. PLoS Negl Trop Dis 2018; 12:e0006418. [PMID: 29659574 PMCID: PMC5919668 DOI: 10.1371/journal.pntd.0006418] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/26/2018] [Accepted: 03/29/2018] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Anna N. Chard
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Victoria Trinies
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Delynn M. Moss
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Howard H. Chang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Seydou Doumbia
- Malaria Research and Training Center, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - Patrick J. Lammie
- Division of Parasitic Diseases and Malaria, Centers for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Matthew C. Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Design, Intervention Fidelity, and Behavioral Outcomes of a School-Based Water, Sanitation, and Hygiene Cluster-Randomized Trial in Laos. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15040570. [PMID: 29565302 PMCID: PMC5923612 DOI: 10.3390/ijerph15040570] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022]
Abstract
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.
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