Swash impacts outcomes
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Transcript of Swash impacts outcomes
SWASH+ impacts and outcomes2006-2012
December 5th, 2012
The TeamCARE: Peter Lochery, Brooks Keene, Malaika Wright, Ben
Okech, Alex Mwaki, Betty Ojeny, John Migele, Jason Oyugi, Peter Waka
Water.org: Liz Were, Caroline Teti, Patrick AlubbeGLUK: Richard Muga, Emily Awino, Imelda AkinyiEmory: Matthew Freeman, Robert Dreibelbis, Leslie Greene,
Shadi Saboori, Kelly Alexander, Victoria Trinies, Bethany Caruso
UF: Richard RheingansGoK: Leah Rotich and the MoE team
Sustaining and scaling school WASH + community impactResearch Question: What is the impact of a school-
based WASH intervention on pupil absence, helminth infection, and diarrhea?
Objective 1: Develop and test a scalable model for school WASH
Objective 2: Determine how to get the government to “take up” proven interventions
Implementation packages based on previous pilotsPost-election violence in 2007-08All findings in addition to effect seen with deworming
The program Research Question
Where we workedSchool locations in Nyanza Province, Kenya
Hygiene promotion and water treatment (HP&WT) (n=45)
HP&WT + Sanitation arm (n=45)
Control (n=45)
Water “available” schools (n=135)
Methods Study arms
Behavior change education
Handwashing promotion
Water treatment
Sanitation
Behavior change education
Handwashing promotion
Water treatment
Helminth schools (n=40) randomly
selected
HP&WT, Sanitation + Water supply (n=25)
Control (n=25)
Water “scarce” schools (n=50)
Methods Study arms
Water supplySanitation
Behavior change education
Handwashing promotion
Water treatment
All students received deworming (3 rounds) regardless of intervention status
Controlling for pupil grade, gender baseline school and community covariates, SES, secular trend, baseline imbalance
Results: AbsenteeismModeling overall effect
No sig. effect of basic intervention on school absenteeism
37% reduction for HP, WT. Significant at <0.1
29% reduction for HP, WT + Sanitation, NS
Freeman MC et al 2012 TMIH
Controlling for pupil age, baseline school and community covariates, SES, secular trend, baseline imbalance
Results: AbsenteeismModeling effect on girls
58% reduction in the odds of absence for the basic intervention
Similar reduction in the schools that also received sanitation
3.4 days of absence avoided per year
Impact of school WASH on absence from school among girls
Freeman MC et al 2012 TMIH
Impacts for CRTHP&WT HP&WT+San HP&WT+San+W
S
Absence OR 0.63 OR 0.71 OR 1.35
Enrollment - Gender parity
+6 pupils per school
PR 1.00
+8 pupils / schoolPR 1.00
+26 pupils per school
PR 1.03
Helminth - A. lumbricoides - Hookworm
--
OR 0.56 / IRR 0.34
OR 0.80 / IRR 0.58
--
Pupil Diarrhea RR 1.00 / IRR 1.03
RR 0.95 / IRR 0.94
RR 0.39 / IRR 0.43
Under 5 diarrhea
RR 1.21 / IRR 1.03
RR 0.76 / IRR 0.94
RR 0.44 / IRR 0.43
Under 5 clinic OR 0.64 OR 0.65 OR 0.36
OR = Odds ratioRR = Risk ratioPR = Prevalence ratioIRR = Incidence rate ratio
Significant <0.01Significant <0.05Significant <0.1
What did we learn and how can we improve school-WASH provision?
The role of latrine cleanlinessThe role of hand cleanlinessGender dimensions
Menstrual hygiene management is a considerable challenge to attendance, concentration and participation
Need a better understanding of the behavioral drivers that resulted in observed impacts
Session 2
Age, gender, and household wealth significant predictors of recent absence.
Household WASH characteristics had a strong association with recent absence
At the school-level, only the quality of school latrines were associated with reduced absence
Role of Latrine CleanlinessBaseline cross-sectional survey
Dreibelbis, R et al IJED
Sanitation intervention did not meet standardsLatrine conditions did not improve
Role of latrine cleanlinessIncreased comfort and use
Basic +Sanitation Control0.0
10.0
20.0
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50.0
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90.0
Basline Final
Basic +Sanitation Control0.0
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80.0
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**significant at 0.05
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Girls per latrine Boys per latrine
Porter S, et al, unpublished data
Even so, we see an increase in comfort and reported use
0 1 2 3 4 5 6 70
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Proportion of block use out of total school useMean proportion of use by block
Prop
ortio
n of
use
58 36 14 9 3 2 1
30
n
Role of latrine cleanlinessProportion of use by latrine for girls
Role of latrine cleanlinessImportant for predicting helminth outcomes
CART analysis
Inconsistent availability of soap
Basic +Sanitation Control0.0
10.0
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Basic +Sanitation Control0.0
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Baseline Final
Handwashing water always available Soap always available
**significant at 0.05
** ******
Role of hand cleanlinessSoap provision is low, handwashing was low
This is one of a few studies that have shown that achieving and sustaining handwashing is a critical challenge
Any E. coli High* E. coli
* ≥ 100 CFU/hand
• Significant increase in hand contamination in sanitation package schools
• No change in schools with basic hygiene promotion
Role of hand cleanlinessSanitation schools: higher hand contamination
1Greene L, Freeman MC, AJTM 2012
Methods• Survey of head teachers in 114 schools.• 6 Focus Group Discussions (FGDs) with girls and boys (age 12-15) in 3 schools.
Results• 111 (97%) reported never providing materials for anal cleansing. • Only 9 schools (8%) actually provided soap & water on the day of the unannounced visit.
• Students confirmed lack of access to anal cleansing materials.• Desired materials, such as tissue paper and schoolbook paper, were described as difficult to
acquire.
‘I find it difficult to get the materials for bottom cleaning. Maybe you have money for food only. Do you go hungry and buy wiping tissue?... …Maybe your younger sibling in class 1 sees you tearing your book, just a sheet or two, but they may get the wrong idea and pluck sheets ruthlessly’
– female student, grade 7, School 1.
Role of hand cleanlinessAnal cleansing materials is a key issue
McMahon, et al, TMIH 2010
InterventionIntervention design was informed by formative research and piloting. 3 Arms: 1. Provision of hand washing and Latrine Cleaning Supplies2. Provision of hand washing supplies3. Control
Methods• 60 schools targeted, 20 in each intervention arm• Absenteeism recorded and School WASH characteristics observed 8 times (May-Nov)• Use observations conducted at baseline, final, and 3 rounds between (5 total per school)
Results• No significant reductions in absenteeism as hypothesized
• Schools that received the LC+HW package had significantly • cleaner latrines at follow-up rounds compared with those that did not receive the intervention.
Role of latrine cleanlinessLatrine maintenance trial
Caruso B, Freeman MC, et al
Methods• 6 Schools: Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) with girls and IDIs
with teachers.
ResultsMenstruation is difficult for girls to manage in the school setting
“A girl will be among the most lively in class, she will participate and make good marks. Then she turns a corner and she will not partake and she is gone.”
- Teacher“You will not be free even when you are in class, you will be thinking about your period and not pay attention to the teacher.”
-Pupil, Standard 8
“The girl with her period is the one to hang her head.”
-Pupil, Standard 7
McMahon, et al, BMC 2010
Gender dimensionsMenstrual hygiene management
How can we improve the sustainability of school WASH?
Recognizing the challenge – SWASH Pilot sustainability
Identifying barriers Tracking progress Testing solutions
Session 3
SWASH pilots established in 2005Short-term follow up of SWASH pilots showed
high level of continued provision of water treatment and soap
In 2008 we conducted follow up in 60 schools (2.5 yrs)
Results were disappointing to partners and others38% provided water for drinking9% had chlorine18% had handwashing water1 school provided soap
Key opportunity for learning within SWASH and beyond
Evaluating Sustainability of SWASH Pilot
Identified barriers to sustained services: internal and external environment
Identified potential solutions (e.g. soapy water) to address them within SWASH schools
Identified ways to monitor these within sustainability toolkit
Domains of an Enabling Environment for Sustaining School WASH
Improved provision over time compared to the pilot, however still low
Over 80 % of schools budgeted for key inputs, but less than 25% budgeted enough
Supply chain for spare parts remained a barrierCommunity wealth and nearby water source associated higher level
of sustaining
Tracking Sustainability for SWASH Trial School
Develop interventions to address sustainability challengesImproved service delivery through funding of
recurrent and maintenance costs and service staff (janitors)
Improved roles and responsibilities trial to test the effects of improved accountability
Key findingsImproved funding can improve provision of basic
services such as treated drinking water and soap for handwashing
Schools have diverse funding needs based on their conditions solutions for some may not work for others
Testing Strategies for Improving Sustainability
Sustainability strongly constrains impactsSchool-level and administrative solutions (e.g.
better planning and M&E) can increase awareness and accountability
Remaining external constraintsCosts: recurrent, maintenance and improvements
School cannot do it on their ownEnvironmental and infrastructure
While some schools can benefit from increased provision of supplies such as drinking water treatment, soap and latrine cleaning supplies, others require basic water and sanitation infrastructure
Sustainability: Key Messages
UNICEF funded a 4 country study on MHM in schools
WASH-B ran a trial of soapy water in B’deshSHARE funded WASH indicators as part of
longitudinal surveillance of STH in KenyaDevelopment of WASH in schools MappingWASH in schools online course for practitioners
and policy makers: 170 students from 50 countriesSPLASH Zambia running an impact study of school
WASH, focusing on sustainabilityDubai Consortium in Mali has funded evaluation of
country-wide program (16m) on educational impacts
Beyond SWASH+