Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
School of Community Health Sciences, University of Nevada Reno, Reno, Nevada, USA.
J Glob Health. 2019 Dec;9(2):020402. doi: 10.7189/jogh.09.020402.
Water, sanitation, and hygiene (WASH) in schools is promoted by development agencies as a modality to improve school attendance by reducing illness. Despite biological plausibility, the few rigorous studies that have assessed the effect of WASH in schools (WinS) interventions on pupil health and school attendance have reported mixed impacts. We evaluated the impact of the Laos Basic Education, Water, Sanitation and Hygiene Programme - a comprehensive WinS project implemented by UNICEF Lao People's Democratic Republic (Lao PDR) in 492 primary schools nationwide between 2013 and 2017 - on pupil education and health.
From 2014-2017, we conducted a cluster-randomized trial among 100 randomly selected primary schools lacking functional WASH facilities in Saravane Province, Lao PDR. Schools were randomly assigned to either the intervention (n = 50) or comparison (n = 50) arm. Intervention schools received a school water supply, sanitation facilities, handwashing facilities, drinking water filters, and behavior change education and promotion. Comparison schools received the intervention after research activities ended. At unannounced visits every six to eight weeks, enumerators recorded pupils' roll-call absence, enrollment, attrition, progression to the next grade, and reported illness (diarrhea, respiratory infection, conjunctivitis), and conducted structured observations to measure intervention fidelity and adherence. Stool samples were collected annually prior to de-worming and analyzed for soil-transmitted helminth (STH) infection. In addition to our primary intention-to-treat analysis, we conducted secondary analyses to quantify the role of intervention fidelity and adherence on project impacts.
We found no impact of the WinS intervention on any primary (pupil absence) or secondary (enrollment, dropout, grade progression, diarrhea, respiratory infection, conjunctivitis, STH infection) impacts. Even among schools with the highest levels of fidelity and adherence, impact of the intervention on absence and health was minimal.
While WinS may create an important enabling environment, WinS interventions alone and as currently delivered may not be sufficient to independently impact pupil education and health. Our results are consistent with other recent evaluations of WinS projects showing limited or mixed effects of WinS.
发展机构提倡学校的水、环境卫生和个人卫生（WASH），认为这是一种通过减少疾病来提高入学率的模式。尽管具有生物学上的合理性，但少数评估学校水、环境卫生和个人卫生（WinS）干预对学生健康和出勤率影响的严格研究报告表明，干预效果存在差异。我们评估了老挝基础教育、水、环境卫生和个人卫生方案（老挝人民民主共和国儿基会在 2013 年至 2017 年期间在全国 492 所小学实施的一项全面的 WinS 项目）对学生教育和健康的影响。
2014 年至 2017 年，我们在老挝沙拉湾省 100 所缺乏功能齐全的 WASH 设施的随机选择的小学中进行了一项集群随机试验。学校被随机分配到干预组（n=50）或对照组（n=50）。干预学校获得了学校供水、卫生设施、洗手设施、饮用水过滤器以及行为改变教育和推广。对照组在研究活动结束后接受了干预。在每六到八周的突击访问中，计数员记录了学生的点名缺席、入学、流失、升级到下一个年级以及报告的疾病（腹泻、呼吸道感染、结膜炎），并进行了结构化观察，以衡量干预的保真度和依从性。每年在驱虫前采集粪便样本进行土壤传播性蠕虫（STH）感染分析。除了我们的主要意向治疗分析外，我们还进行了二次分析，以量化干预保真度和依从性对项目影响的作用。
我们没有发现 WASH 干预对任何主要（学生缺勤）或次要（入学、辍学、年级升级、腹泻、呼吸道感染、结膜炎、STH 感染）影响有任何影响。即使在保真度和依从性最高的学校中，干预对缺勤和健康的影响也很小。
虽然 WASH 可能创造了一个重要的有利环境，但 WASH 干预本身以及目前的实施方式可能不足以独立影响学生的教育和健康。我们的结果与其他最近对 WASH 项目的评估结果一致，表明 WASH 的效果有限或混合。
