Impact of Simple Handwashing & Drinking Water Stations and Hygiene

Education on Student Hygiene Practices & Health in Kenyan Primary

Schools

Saduma Iphreem Ibrahim

Safe Water and Aids Project – Kisumu Kenya

• Diarrheal diseases cause 1.34 million deaths globally per year– Most occur among children <5 years old in developing

countries• Important contributors to diarrhea risks include:

– Lack of access to improved water– Poor hygiene

• Proven strategies to prevent diarrheal disease in resource-poor settings include:– Point-of-use water treatment– Handwashing with soap

• Promising approach to implement these strategies– School-based water treatment and hygiene programs

Background

• Students learn new habits that can last a lifetime

• Healthy students miss less school and learn more

• Children can transmit lessons to parents

Rationale for School-Based Implementation

• Increase in water treatment and handwashing knowledge*

• Decreased diarrhea rates**

• Decreased absenteeism*

*O’Reilly, et al. Epidemiology Infect 2007; doi:10.1017/S0950268807008060* Blanton, et al. AJTMH 2010.; 82(4), 2010, pp. 664–671**Migele, et al. AJTMH 2007; 76(2), 2007, pp. 351–353

Results of Previous School Programs in Western Kenya

Nyando Integrated Child Health and Education Project (NICHE)

Purpose: • Increase access to health information, water treatment

products, safe water storage containers, soap, and other interventions

Approach: Integrated implementation• Social marketing• Health promotion and product sales by HIV self-help groups

organized by the Safe Water and AIDS Project (SWAP)• Installation of water stations in schools and clinics• Health promotion by teachers and health workers

Nyanza Province, Kenya

Nyando Division

L. Victoria

NYANZA PROVINCE

(Pop. 80,000)

Objective

Determine impact of the NICHE school program on pupils’ hand washing knowledge and health

Methods• Two-stage cluster sampling strategy

– First stage: village level• Intervention group: 30 villages• Comparison group: 30 villages• Probability of selection proportional to size

– Second stage: household level• Census of 60 study villages• Random sample of households with a child <3yo

• School selection– Intervention schools (n=21): located in intervention villages– Comparison schools (n=22): located in comparison villages

• Pupil selection– All pupils in grades 4-8 living in households selected for

study

Baseline Data Collection (March 2007)

• Pupil interviews – Reported hand washing at school

– Ability to demonstrate proper hand-washing technique

• Caregiver interviews– Demographic & SES

− Reported HH illnesses

Implementation of InterventionIntervention schools (April-May 2007):• Teacher training: hand washing and water treatment• Instruction materials for students• Hand washing stations: installed near latrines

– 60 liter plastic buckets with lids and taps– Metal stands– 3-month “starter” supply of soap

• Drinking water stations: installed near classrooms– 60 liter plastic buckets with lids and taps– Metal stands– 3-month supply of WaterGuard

• Comparison schools (April-May 2008)

Evaluation Timeline

March 2007

Baseline

Mar 2008

April 2007

Bi-Wkly active Surveillance

Year 1

ImplementationIntervention schools

Follow-up 1

Bi-Wkly active SurveillanceYear 2

April2008

Follow-up 2

ImplementationComparison schools

Mar 2009

Data Analysis• Data are presented as school level aggregates:

– Medians (interquartile range 25-75%)• To compare pupil responses between intervention and

comparison schools, we estimated differences in medians (EDM)– Calculated for each cross sectional survey– Represent an estimated effect size– Because of small number of schools, we report 90% confidence

intervals (CI)– Differences are considered significant if the CI does not cross zero

• EDM is also used to compare active surveillance data– For each year of surveillance, data were aggregated at school level– Median illness rates compared between intervention and comparison

schools

RESULTS

Study Population

378 students

262 students

187 students

405 students

216 students

140 students

Intervention Comparison

116 students lost to follow-up

189 studentslost to follow-up

76 studentslost to follow-up

75 studentslost to follow-up

Baseline

Follow-up 1

Follow-up 2

Baseline Characteristics

• Median % of female HH caregivers

100 (94--100), Age 37 (30--45)

• <1% have electricity

• 75% live in 1 room homes

• 97% have mud walls

• 60% have iron roofs

• 48% drink surface water

Median Percentage of Pupils Reporting Hand Washing at School and Demonstrating Proper Hand Washing

Technique

BASELINE (2007) FOLLOW UP YEAR 1 (2008)

FOLLOW UP YEAR 2 (2009)

BehaviorINT

(range)COMP(range)

EDM(90% CI)

INT(range)

COMP(range)

EDM(90% CI)

INT(range)

COMP(range)

EDM(90% CI)

Reportedwashing HandsWhile atschool

76 (42-88)

56 (38-72) 23 (3-39)

100 (93-100)

40 (25-54) 60 (53-73) 100 100 0

ShowedProperHW skills

31 (25-48)

32 (14-42)

4 (-11-19)

46 (30-75)

14 (0-33) 32 (10-46) 54 (33-

100)50 (31-

75)0 (-17-

11)

Median Percentage of Caregivers Reporting Pupil Illness During Active Surveillance Visits

YEAR 1 YEAR 2

INT

(range)

COMP

(range)

EDM

(90% CI)

INT

(range)

COMP

(range)

EDM

(90% CI)

Any illness 5 (4-7) 7 (6-9) -3 (-4- -1) 3 (2-3) 2 (1-3) 1 (-1-1)

Diarrhea 0 (0-0.3) 0.3 (0-0.6) 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0)

Acute respiratory

Illness2 (1-4) 3 (3-6) -2 (-3- -1) 0.8 (0-1.5) 0.7 (0.3-1.5) 1 (-1-1)

Limitations• Illness outcomes were reported and

not clinically confirmed

• Biweekly home visits could have

resulted in respondent fatigue and

lowered rates of reported illness

• High pupil loss to follow-up through

graduation and dropping out

• Results not generalizable

Conclusions• School-based hygiene intervention appeared to

reduce the risk of overall reported illness and respiratory infections– Lower rates in pupils in intervention schools in year 1– Similar rates in both groups in year 2 after

implementation of intervention in comparison schools• School-based hygiene intervention appeared to

improve handwashing behavior– Higher reported handwashing in school and ability to

demonstrate proper hygiene technique among intervention pupils in year 1

– Similar rates in both groups in year 2

Acknowledgements

CDCMinal K. Patel Julie R. Harris Patricia Juliao Benjamin NygrenRobert Quick

SWAPAlie Eleveld

NICHE-Kenya TeamVincent WereSteve KolaSitnah Hamidah FaithRonald Otieno

Ministry of EducationSchool Teachers

sadumah@swapkenya.orgwww.swapkenya.org

Thank You!