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

Abstract

Abstract. Studies 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.

Quantitative Microbial Risk Assessment of Drinking Water Quality to Predict the Risk of Waterborne Diseases in Primary-School Children

“…The delivery of improved water at schools can contribute to the improved health and educational performance. Further, water helps to maintain environmental and personal hygiene, decrease chances of dehydration at schools, and ultimately contribute to improved cognitive abilities [27,46]. The geographical differences in pathogen-related health risks between North and South Sindh were likely due to different types of water sources.…”

“…The headmaster of each school was interviewed, and drinking-water samples and structured observations of WASH were collected. ODK Collect Android Software was used to collect survey data [27]. Structured observations of water facilities were carried out, to assess the availability, accessibility, and functionality of water facilities.…”

Factors perceived to facilitate or hinder handwashing among primary students: a qualitative assessment of the Mikono Safi intervention schools in NW Tanzania

“…While school-based WASH interventions in low-income and middle-income countries have been examined with regards to a wide range of health and educational outcomes, including: diarrhoea, respiratory infection, school attendance and health outcomes in the domestic environment,9–13 these studies have shown that the impact on such outcomes is inconsistent. For the most part, this variability has been viewed through the lens of intervention fidelity and compliance— the extent to which schools and/or implementing organisations have provided WASH services in schools routinely and in a manner consistent with intervention protocols 14 15. However, for school-based hygiene interventions to result in health or educational impacts, they must also successfully change students’ hygiene behaviours.…”

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

“…Matched comparison schools were located within the same educational district and matched to beneficiary schools based on baseline enrollment size and school WASH characteristics. Detailed methods of the parent study and the as-treated analysis are described elsewhere [ 14 , 17 ]. In each school, 20 pupils were randomly selected from a list of all pupils enrolled in classes 1–6 using stratified random sampling based on pupil sex and grade.…”

“…Despite the biological plausibility supporting the role of improvements in school WASH conditions on pupil health, results from school WASH evaluations have been mixed [ 6 – 12 ]. There is some evidence of associations between WASH in schools programs and reductions in diarrhea, acute respiratory infection, soil-transmitted helminth re-infection, and school absence, but results are inconsistent and effects are sometimes evident only among sub-populations [ 6 , 8 , 9 , 13 – 17 ].…”