Understanding the Role of WASH Interventions in Schools
Improving access to water, sanitation, and hygiene (WASH) in schools can play a crucial role in reducing the transmission of infectious diseases and fostering better health and educational outcomes among students. Studies have shown that comprehensive school-based WASH interventions have the potential to reduce the incidence of diarrheal disease, respiratory illness, and soil-transmitted helminths, particularly when paired with effective hygiene promotion efforts.
However, the evidence on the impacts of school WASH programs has been inconsistent, with some studies reporting positive effects on health and attendance, while others have found little to no impact. This variability in results may be attributed, in part, to suboptimal program fidelity and adherence – that is, the degree to which the intended WASH interventions are actually implemented and adopted by the target schools and communities.
Measuring Fidelity and Adherence in a School WASH Program in Mali
As part of a matched-control study of a comprehensive school-based WASH project in Mali, researchers set out to evaluate the degree to which the participating schools were able to meet pre-specified WASH performance targets and criteria. The DCIM (Dubai Cares Initiative in Mali for WASH in Schools) program, implemented between 2011-2014, provided water supply, sanitation infrastructure, handwashing facilities, and hygiene education in over 900 primary and secondary schools across six regions of Mali.
The researchers identified four main WASH performance targets, each composed of 3-5 specific criteria, for a total of 15 elements to assess. These targets covered:
1. Water Supply: Provision of a functional water point at the school
2. Sanitation: Adequate number of usable, sex-separated, and clean latrines
3. Handwashing: Availability of handwashing water, soap, and cleaning supplies
4. WASH Supplies: Provision and maintenance of items like soap, cleaning materials, and hygiene kits
The researchers then compared the achievement of these WASH targets and criteria between the 100 beneficiary schools that received the DCIM intervention and 100 matched control schools that did not. They also assessed changes in target achievement within the beneficiary schools over time, from baseline to follow-up visits 0-3 years after program implementation.
| WASH Performance Targets | Criteria |
|---|---|
| Water Supply |
– Presence of a functional water point – Sufficient number of water points – Accessibility of water points |
| Sanitation |
– Sufficient number of usable latrines – Sex-separation of latrines – Cleanliness of latrines |
| Handwashing |
– Availability of handwashing water – Presence of soap at handwashing stations – Availability of cleaning supplies |
| WASH Supplies |
– Presence of soap – Availability of hygiene kits – Presence of cleaning materials |
Exploring the Impact of WASH Target Achievement
The researchers then conducted an “as-treated” analysis to assess the associations between achievement of the WASH targets – both individually and collectively – and key health and educational outcomes among the students, including:
- Diarrhea: Pupil-reported diarrhea in the past week
- Respiratory Symptoms: Pupil-reported respiratory infection symptoms in the past week
- Absence: Roll-call absence and pupil-reported absence in the past week
This “as-treated” approach allowed the researchers to move beyond the standard intention-to-treat analysis and examine the extent to which the actual implementation and adherence to the WASH interventions impacted student health and attendance, rather than just the average effect of the overall program.
Key Findings on Fidelity, Adherence, and Impacts
The results of the study revealed several important insights:
Fidelity and Adherence:
* Between 44% and 81% of beneficiary schools achieved each of the four WASH performance targets on average across follow-up visits.
* Beneficiary schools met significantly more WASH targets than the matched control schools.
* Beneficiary schools also met more WASH targets at follow-up compared to baseline, indicating improved adherence over time.
* However, adherence was inconsistent, with some schools struggling to maintain all WASH components.
* Schools that received the intervention more recently (in 2013) tended to perform better on the WASH targets than those that received it earlier (in 2011-2012).
Health and Educational Impacts:
* Achieving the sanitation target was individually associated with lower odds of pupil-reported diarrhea.
* Increasing achievement of multiple WASH targets together (water, sanitation, handwashing, supplies) was associated with lower odds of both diarrhea and respiratory symptoms among students.
* However, WASH target achievement was not associated with reductions in roll-call absence or pupil-reported absence.
These findings suggest that a comprehensive school-based WASH program, coupled with a focus on maximizing fidelity and adherence to the various WASH components, may be necessary to realize meaningful improvements in student health. While WASH alone may not be sufficient to decrease absenteeism, addressing multiple transmission pathways through a multi-faceted WASH approach appears crucial for generating positive impacts on diarrheal and respiratory disease.
The researchers note that the “as-treated” analysis, which examines the effects based on actual implementation and uptake rather than just the average program effect, provides important insights that can supplement the typical intention-to-treat findings. This approach helps uncover the true potential of WASH interventions when they are properly implemented and adopted by schools and communities.
Implications and Recommendations
The results of this study in Mali highlight several important considerations for the design, implementation, and evaluation of school-based WASH programs:
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Comprehensive Approach: Implementing a multi-faceted WASH program that addresses water supply, sanitation, handwashing, and hygiene supplies may be more effective for improving health outcomes than single-component interventions.
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Ensuring Fidelity and Adherence: Programs should prioritize strategies to maximize the achievement and maintenance of WASH targets at the school level, as inconsistent implementation and uptake can undermine potential health benefits.
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Monitoring and Evaluation: Rigorous monitoring of WASH outputs and outcomes, as well as detailed process evaluation, are critical for understanding the true impact of these interventions. “As-treated” analyses can provide important supplemental insights beyond the standard intention-to-treat approach.
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Addressing Non-WASH Factors: While WASH is a crucial component, factors unrelated to the school environment, such as socioeconomic status, may also influence student health and attendance. Addressing these broader determinants in a holistic manner could further enhance the impacts of school WASH programs.
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Sustained Commitment: Maintaining WASH infrastructure and behaviors over the long-term requires ongoing engagement, resources, and institutional support. Programs should consider strategies for ensuring sustainable impact, such as strengthening school management committees and leveraging community involvement.
By incorporating these lessons into the design and implementation of future school WASH initiatives, practitioners and policymakers can work to maximize the health and educational benefits for students, while also contributing to the growing body of evidence on effective WASH programming in school settings.
To learn more about the Joint Action for Water network and stay up-to-date on the latest developments in the water and sanitation sector, please visit https://jointactionforwater.org/.
