The poor access to water supply is a prevalent issue in over 850 million people worldwide with over 2.5 billion limited by access to sanitation facilities [
Previous literature has shown considerable studies regarding the effects of lack of appropriate water facilities, hand washing, and hygiene practices on child health outcomes. Impaired cognitive learning and learning performance are long-term outcomes of the negative effects of infections such as diarrhea, worm infestations, and dehydrations which are largely attributed to poor water, sanitation, and hygiene conditions [
“Attendance is a strong predictive factor of academic success for elementary school pupils” [
There have been considerable studies that have examined the effect of water treatment, hygiene, and sanitary practices on reducing absenteeism, diarrhea prevalence, and acute respiratory infections in school-age children. However, limited research has been done to evaluate the effectiveness of water, sanitation, and hygiene practices through randomized controlled clinical trials to gauge the long-term impact of these interventions on improving child health outcomes. The objective of the study is to examine and describe the gaps in the existing water, sanitation, and hygiene interventions to improve child health outcomes such as acute respiratory infections, diarrheal episodes, and absenteeism in various settings.
A search was conducted in January 2013 using the scientific databases PubMed and Google scholar for studies published between 2009 and 2012 and focusing on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children. Key words were used either in single form or in combination and included “Water access and Waterborne illnesses,” “School enrollment and Hygiene education,” “Hand washing facilities and absenteeism,” and “Hygiene education and children.” Studies included were those that documented the provision of water and sanitation in schools for children less than 18 years of age, interventions which assessed the impact of WASH practices, and English-language, full-text peer reviewed papers. Studies which did not have a school-based component in assessing WASH practices were excluded. A secondary search was also done to review the references of the articles included in the final analysis.
The initial search yielded 287 studies including the secondary research. This was reduced to 15 studies after the exclusion criteria were applied and duplicates removed (Figure
Flow chart showing procedures undertaken in article selection.
Age/grade level: comparisons of the effectiveness of WASH interventions were reported for some of the studies stratified by various age categories and measured in years. Gender: the gender of the children in the various studies was noted to observe if there were any differences in the effectiveness of the interventions. Socioeconomic status/household income: information on socioeconomic status was abstracted from the articles to observe its significance towards promoting access to water facilities and improving hygiene practices in children. Parental literacy: it was assessed to monitor the effect of role-modeling behaviors in children towards imbibing knowledge, attitudes, and practices of sanitation and hygiene.
Study design: information was gathered to determine the types of studies that were performed including randomized controlled trials, cross-sectional studies, cohort studies, and case series. Study location: information was gathered about the locations where the studies were conducted. Study duration: the period of the study was also recorded. Sample size of the populations: it was also recorded.
Knowledge: knowledge, as an educational component of the various studies reviewed, was assessed to observe their effects on sustained impact of the interventions. Comparisons were also made to interventions that did not utilize this component to weigh its effectiveness.
The outcomes assessed included absenteeism, diarrhea, and malnutrition in children.
The commonly studied age groups of children studied fell between 5 years and 16 years (53%,
40% (
Number of studies across various continents.
More than half (53%,
100% (
The total sample size ranged from 76 to 44451 children. 53% (
The data collection process was carried out using surveys at several levels including students, parents, teachers, health workers, social workers, or a combination of them (Figure
Chart showing the different units of analysis.
Several variable categories were gathered based on the literature review of the articles included in the final analysis. These include the following.
The socioeconomic index was described in the studies reviewed to include wealth index, wealth, household income, household assets, and housing type. 60% of the studies analyzed the association between socioeconomic index and the outcomes (
Family size (26.6%,
Latrine coverage in schools was the most common variable assessed (60%,
The major data on environmental characteristics collected in most studies were those regarding drinking water sources in households (46.6%,
20% (
Other data collected in the studies reviewed included nasal swab samples (for influenza testing), age of respondents, crowding index, sewage spillage, and contaminated fomites. Each variable in the particular category has been described in detail below.
Table showing independent variables assessed.
Categories | Variables | Number of studies assessing variables | Study location | Impact on outcomes | ||
---|---|---|---|---|---|---|
Rural based | Urban based | Rural based | Urban based | |||
Sociodemographics | Age | 12 | 6 | 6 | 2 | 1 |
Gender | 12 | 7 | 5 | 1 | 2 | |
Knowledge | 12 | 6 | 6 | 5 | 6 | |
Household income | 9 | 5 | 4 | 3 | ||
Grade level of children | 6 | 3 | 3 | 2 | 1 | |
Maternal education | 2 | 2 | 2 | 1 | ||
Parental occupation | 1 | 1 | ||||
Parent education | 5 | 4 | 1 | 3 | ||
| ||||||
Household variables | Female-headed households | 3 | 2 | 1 | 1 | 1 |
Distance to school from home | 1 | 1 | ||||
Distance to water source | 2 | 1 | 1 | |||
Family size | 4 | 3 | 1 | 1 | ||
No. of people sharing bedroom with child | 1 | 1 | ||||
No. of people sharing toilet with child | 1 | 1 | ||||
No. of children <5 yrs in household | 2 | 1 | 1 | 1 | ||
| ||||||
School characteristics | School area/location (highland/lowland) | 2 | 2 | 1 | ||
Latrine coverage | 9 | 6 | 3 | 3 | 1 | |
Pupil-latrine ratio | 1 | 1 | ||||
Water source at school | 2 | 1 | 1 | 1 | ||
Hand washing soap on basin | 1 | 1 | ||||
Means of waste disposal | 1 | 1 | ||||
Washup point after toilet | 1 | 1 | ||||
| ||||||
Environmental and access | Water source contamination | 1 | 1 | 1 | ||
Water samples | 4 | 3 | 1 | |||
Chlorine testing | 3 | 2 | 1 | |||
Water access/availability | 1 | 1 | ||||
Drinking water sources | 7 | 5 | 2 | 3 | ||
Climatic season | 2 | 1 | 1 | 1 | ||
| ||||||
Nutrition practices | Food handling | 2 | 1 | 1 | ||
Meat consumption/eating raw vegetables/eating orange peels | 1 | 1 | ||||
Acute malnutrition | 1 | 1 | ||||
Stool samples | 1 | 1 | ||||
| ||||||
Knowledge, attitudes, and practices | Prior knowledge of hygiene practices and water treatment | 7 | 6 | 1 | 4 | 1 |
Use of soap | 7 | 3 | 4 | 3 | 4 | |
Latrine coverage (school/household) | 9 | 6 | 3 | 3 | 1 | |
Hand washing | 10 | 6 | 4 | 4 | 4 | |
Sanitation practice (latrine use) | 8 | 5 | 3 | 5 | 3 | |
Drying material availability | 1 | 1 | 1 | |||
Household water treatment | 2 | 2 | 2 | |||
Water storage practices | 3 | 3 | ||||
Hygiene practices | 3 | 2 | 1 | 2 | 1 |
The interventions included in the final analysis were in single form or in combination. These are outlined below.
There was only one study that examined the impact of hygiene practices on absenteeism due to infectious illness among pupils in elementary schools. The study was conducted in Denmark. Two schools comprising 652 students were randomized into an intervention and a control group. The students at the intervention school were required to wash their hands before the first lesson, before lunch, and before going home while those at the control school continued their usual hand washing practices. The rates of absenteeism for the students in the intervention school were significantly reduced compared with those in the control school (
There were 4 studies that examined the impact of the combination of hand hygiene instructions and provision of hygiene facilities. They included both US- and non-US-based studies conducted in Texas, Chicago, Egypt, and Pittsburgh.
The study conducted in North Texas was geared towards controlling a Shigella outbreak in an elementary and middle school [
The study conducted in Egypt assessed the effects of hand hygiene campaigns on the incidence of laboratory-confirmed influenza and absenteeism in school children [
In another randomized controlled trial, children in 5 intervention schools received training about hand and respiratory hygiene and were provided and encouraged to use hand sanitizer regularly while the children in the other 5 schools acted as controls. Prior to implementation of the interventions, there was a 45-minute presentation at intervention schools regarding influenza and proper hand washing technique and sanitizer use. Hand sanitizer dispensers with 62% alcohol-based hand sanitizer were installed in each classroom and all major common areas of intervention schools. The children were required to utilize it several times daily including upon arrival, before and after lunch, and prior to departure was taught to students. They were also encouraged to wash hands or use additional doses of hand sanitizer as needed. The total absence episodes were significantly reduced among children in the intervention group compared to the controls, adjusted IRR 0.74 (95% CI: 0.56, 0.97).
There were 3 randomized controlled trials that utilized a combination of water treatment and hygiene practices and education (Kenya,
In another study conducted in Kenya, the role of school children in the promotion of point-of-use water treatment and hand washing in schools and their impact on reducing pupil absenteeism rates was evaluated [
Only one study was conducted in Kenya which utilized multiple intervention components involving water treatment, hygiene promotion, and sanitation to assess their impact on pupil absence [
The studies reviewed assessed 4 major outcomes of the effect of water and sanitation hygiene practices in children. These included absenteeism, infections (diarrhea/acute respiratory), knowledge/attitudes/practices, and adoption of point of use water treatment (Table
Description of the outcomes assessed and interventions utilized.
Interventions | Locations | Results/significance | Grade level | |
---|---|---|---|---|
Absenteeism | Hygiene education, hygiene practices, and access to sanitation facilities | Cambodia, Kenya, US, Egypt, and Denmark | Yes | 1–8 |
| ||||
Infections (diarrhea, respiratory, and gastrointestinal) | Hygiene education, water treatment, and access to hygiene resources such as installation of water stations and provision of hand sanitizers | US, Egypt, Denmark, and Zimbabwe | Yes | 1–8 |
| ||||
Adoption of point of use water treatment | Water treatment and education on hygiene practices | India | Yes (not statistically significant) | Not specified |
Information regarding absenteeism was defined and collected differently in the various studies reviewed [
Five studies assessed the impact of WASH practices on reducing absenteeism. Illness-related absenteeism children constitutes about 75% of all school absences [
The variables assessed regarding knowledge, attitudes, and practices included knowledge of prior water treatment, use of soap/sanitizer (46%,
The most common infections included diarrheal and acute respiratory infections. 46% (
Only 2 of the studies reviewed assessed adoption of point of use water treatment. The studies were conducted in India, (
Results of our systematic review yielded fifteen studies which assessed the impact of WASH practices to improve the knowledge, attitudes, practices, and child health outcomes. These health outcomes include absenteeism, diarrhea, acute respiratory infections, and adoption of point of use water treatment. More than half of the studies (53%,
Higher rates of infection by helminthes and protozoa were more prevalent in the younger age group consisting of children aged 7-8 years old compared to the older children aged 8 to 10 years [
The most commonly assessed variables with highest significance were latrine coverage and hand washing practices while the least commonly assessed were school characteristics including pupil-latrine ratio, availability of soaps in toilets, water source contamination, water availability, drying material availability, and several household variables including number of people sharing bedroom or toilet with child. This review showed that several independent variables were implicated in the adoption of WASH practices and found to be significantly associated with the outcomes. These variables should be carefully studied in future randomized controlled interventions. They include the age of the child, gender, grade level, socioeconomic index, access to hygiene and sanitary facilities, and prior knowledge of hygiene practices.
All the studies done in developing countries reported a positive effect of sanitation practices on reducing diarrhea prevalence [
This review identified a gap in assessment of nutrition practices which is a key factor related to the various outcomes studied especially diarrheal infections and should therefore be given more attention in future research. The studies assessed the health and educational effects of WASH practices in schools on reducing absenteeism and diarrhea prevalence/infections among school-age children on a short term. However, there have been little or no empirical studies which examined the long term impact of WASH interventions on child health outcomes, and therefore limited data to support future interventions. This was noted as a limitation in various studies showing a high loss to followup, where followup was present [