The impact of a school-based water, sanitation and hygiene program on health and absenteeism of primary school children

Freeman, Matthew Charles; (2011) The impact of a school-based water, sanitation and hygiene program on health and absenteeism of primary school children. PhD thesis, London School of Hygiene & Tropical Medicine. DOI:

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This thesis describes research designed to quantify and describe the impact of improved access to school water, sanitation, and hygiene (WASH) access on pupils' helminth infection and diarrhoeal disease and absence from school. The research was undertaken as part of a five-year cluster-randomized trial in 185 public primary schools in Nyanza Province, Kenya that addressed school WASH impacts, knowledge diffusion, sustainability, and advocacy. One hundred eighty-five schools were randomly selected and assigned to five study arms to receive various water treatment, hygiene promotion, sanitation, and water supply improvements. All pupils at enrolled schools were dewormed at baseline and at two follow-up time pOints. A total of 11,458 pupils were interviewed over two years to compare rates of school absence, rates and intensity of reinfection with soil transmitted helminths, and risk of diarrhoeal disease. We found no overall impact of our school-based WASH intervention on pupil absence. However, a domain analysis revealed a substantial and significant reduction in absence for girls attending schools that received WASH improvements. Schools that received a hygiene promotion and water treatment (HP&WT) intervention showed statistically similar reductions to those that received HP&WT in addition to sanitation improvements. Gender-specific effects were also found for reduced reinfection of soiltransmitted helminth infection. Girls showed a significant decline in prevalence and intensity of infection with Ascaris lumbricoides, while boys showed reduced reinfection for Hookworm. Household WASH characteristics significantly modified the effect of the school-based intervention, revealing potential questions about exposure to fecal pathogens at home and at school. Schools that received HP&WT and those that received HP&WT plus sanitation improvements showed no reduction in diarrhoeal disease prevalence. However, schools allocated to the water "scarce" research group, which received water supply improvements in addition to HP&WT and sanitation, did show significant and substantial reductions in both prevalence and duration of diarrhoeal illness. While household-level WASH has been investigated extensively, this is the first comprehensive study to investigate the impact of improved WASH at schools. Overall, our results reveal the important role that school WASH can play in mitigating disease burden and lowering pupil absence. Additional research is necessary to fully explore these issues.

Item Type: Thesis
Thesis Type: Doctoral
Thesis Name: PhD
Contributors: Clasen, T (Thesis advisor);
Additional Information:
Faculty and Department: Faculty of Infectious and Tropical Diseases > Dept of Disease Control


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