Health Stream Literature Summary - Issue 50 - June 2008

The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006
O'Reilly, C.E., Freeman, M.C., Ravani, M., Migele, J., Mwaki, A., Ayalo, M., Ombeki, S., Hoekstra, R.M. and Quick, R. (2008) Epidemiology & Infection, 136(1); 80-91.

Contaminated drinking water contributes greatly to the estimated 3-5 billions episodes of diarrhoea that occur annually, of which 80% occur among children under 5 years. The Safe Water System (SWS) was developed to prevent diarrhoea by the promotion of household water treatment, safe water storage and behaviour change communications. In Kenya, CARE implemented a SWS programme in Nyanza Province in 2000 because of high diarrhoeal disease burden and poor drinking water access. In 2003, a social marketing campaign was initiated to sell bottles of SWS disinfectant solution (dilute sodium hypochlorite) under the name of WaterGuard®. There were over 800,000 bottles of WaterGuard sold in 2005 each of which can treat 1,000 L of water. In February 2005 the SWS was implemented in 45 primary schools in three districts of Nyanza Province. Two teachers were trained in each school on SWS use and proper handwashing practices (including six steps). Teachers were provided with training materials and instructed to form safe water clubs with students, teach SWS and hygiene to students and encourage them to teach their parents. Participating schools were given clay pots modified for safe storage with a narrow mouth, lid and spigot; a years’ supply of WaterGuard to treat water for drinking and handwashing; 200-l plastic water tanks with taps for handwashing and soap. An evaluation was conducted one year later to determine if this school-based SWS and hygiene programme improved knowledge, attitudes and practices concerning water handling and hygiene among school children and their parents.

There were three schools from each of the three districts selected for evaluation. The head teacher from each of the nine schools was interviewed twice using a standard questionnaire - once at baseline and then for the final evaluation about the number of teachers, students and functioning latrines; drinking water collection, storage and treatment practices; handwashing facilities; and soap availability at school. Stored drinking water was tested where available for free chlorine residual.

In May 2005, a random sample of 390 students in grades 4-8 from the nine project schools was selected for a baseline survey and in February 2006 a new random sample of 363 students in grades 4-8 from the same schools was selected for the final evaluation. Students were interviewed about knowledge, attitudes and practices concerning water sources, water storage, water treatment, handwashing, sanitation and sources of health information. During the final evaluation a similar questionnaire was administered with extra questions specific to the SWS and handwashing training and students were observed washing their hands to assess whether they used correct practices.

A baseline household survey was conducted in the homes of the 390 selected students and in the homes of the 363 students selected for the final evaluation. The baseline household questionnaire included questions about household demographic and socio-economic characteristics, water sources, water handling and hygiene practices, sanitation and sources of health information. Observations were made about water storage vessels, handwashing facilities and latrines and stored drinking water was tested for residual free chlorine. The final evaluation was similar to the baseline survey with additional questions specific to the SWS and handwashing intervention. Parents’ handwashing practices were observed to determine whether they could reproduce the method taught to students.

At baseline, seven of the schools reported that they provided water to their students and in the final evaluation all nine schools had functioning water storage vessels and handwashing tanks. In the final evaluation, containers in eight schools were filled with water and seven had detectable chlorine residuals in all drinking water and handwashing vessels. The median number of latrines at the schools at baseline was six with a ratio of students per latrine of 42:1 (range 26-264). At the final evaluation the number of latrines per school had increased to 10 and the ratio per student was 35:1 (range 24-57). In the final evaluation 99% of students indicated they drank water at school from the project storage containers. At baseline 69% of students believed that the drinking water in their school was not treated. In the final evaluation 99% of students had heard of WaterGuard and 100% indicated that their school used it to treat drinking water. The correct dose of WaterGuard was correctly stated by 21% of students at baseline and 65% of students at the final evaluation which was a statistically significantly increase (P less than 0.01). Student’s knowledge of how to wash their hands increased substantially from baseline to final evaluation with over half of the students able to demonstrate at least three of the six key steps on handwashing they had been taught.

At baseline, 47% of parents/guardians reported boiling water and 11% reported using WaterGuard while in the final evaluation, 42% reported boiling and 35% used WaterGuard. At baseline, 79% of parent/guardians had heard of WaterGuard but only 25% had ever used it whereas in the final evaluation, awareness of WaterGuard had increased to 91% and 46% of parents/guardians reported ever using it. In a univariate analysis of water treatment, a significantly higher proportion of households at the final evaluation reported ever using WaterGuard (P less than 0.01) and currently using WaterGuard (P less than 0.01) than at baseline. There was a trend seen towards increased awareness of WaterGuard (P=0.07) and correct WaterGuard treatment procedure (P=0.08) from baseline to final evaluation. On weighted univariate analysis, soap was observed in 74% of households at baseline and 90% at final evaluation (P less than 0.01). When demonstrating how to wash their hands, 76% of parents/guardians used soap and 38% were able to demonstrate four of the six key handwashing steps taught to their children.

To determine whether the project had an impact on student absenteeism, data was collected from weekly absenteeism reports for 2004 and 2005 by each of the nine projects schools and for nine neighbouring non-project schools for comparison. The rate of absent students per person week was 35% lower during the 2005 September-November school term than the 2004 September-November term. In contrast for the same period the absenteeism increased in the nine neighbouring comparison schools by 5%.

This evaluation suggests that safe water and hygiene knowledge transfer look place from teacher to student following training and the installation of handwashing and drinking stations in public schools in rural western Kanya. The evaluation also demonstrated that water treatment and hygiene knowledge transfer from student to parent resulted in some behaviour change among parents. This program shows promise for reducing absenteeism by improving the quality of the school environment.