The Role of Adherence on the Impact of a School-Based Water, Sanitation, and Hygiene Intervention in Mali

Joshua V. Garn Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Search for other papers by Joshua V. Garn in
Current site
Google Scholar
PubMed
Close
,
Victoria Trinies Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Search for other papers by Victoria Trinies in
Current site
Google Scholar
PubMed
Close
,
Jérémie Toubkiss Evaluation Office, The United Nations Children's Fund, New York, New York.
The United Nations Children's Fund Mali, Bamako, Mali.

Search for other papers by Jérémie Toubkiss in
Current site
Google Scholar
PubMed
Close
, and
Matthew C. Freeman Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Search for other papers by Matthew C. Freeman in
Current site
Google Scholar
PubMed
Close
Restricted access

Studies assessing the impacts of school-based water, sanitation, and hygiene (WASH) interventions have revealed inconsistent improvements in pupils' health and educational outcomes. This may be in part due to suboptimal project fidelity or adherence. As part of a matched-control trial of a comprehensive school-based WASH project in Mali, we measured the degree to which schools met four prespecified WASH targets, comprised of 15 criteria, 0–3 years after program implementation. We compared achievement of the targets and criteria between beneficiary and matched control schools, and compared achievement within beneficiary schools at baseline and at follow-up visits. We assessed the “as-treated” associations between WASH target achievement and pupil diarrhea, respiratory symptoms, and absence. Between 44% and 81% of beneficiary schools achieved each target. Although adherence was inconsistent across schools, beneficiary schools, on average, met more WASH targets than matched control schools, and beneficiary schools also met more WASH targets at follow-up than at baseline. Very few of the targets were individually associated with health and absenteeism outcomes. Increasing achievement of multiple WASH targets together was associated with a lower odds of pupils having diarrhea (P trend < 0.01) and having respiratory symptoms (P trend < 0.01), but was not associated with roll-call absence (P trend = 0.14) or pupil-reported absence (P trend = 0.41). These results indicate that a comprehensive WASH intervention and a focus on increasing adherence may help maximize the health effects of school WASH programs, but that WASH alone might not be sufficient to decrease pupils' absenteeism.

Author Notes

* Address correspondence to Matthew C. Freeman, Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, CNR 2027, Atlanta, GA 30322.
† These authors contributed equally to this work.

Financial support: Funding for this impact evaluation was provided by Dubai Cares Foundation.

Authors' addresses: Joshua V. Garn, Victoria Trinies, and Matthew C. Freeman, Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, E-mails: jgarn@emory.edu, vtrinies@gmail.com, and matthew.freeman@emory.edu. Jérémie Toubkiss, Evaluation Office, The United Nations Children's Fund Headquarter, New York City, NY, E-mail: jtoubkiss@unicef.org.

  • 1.

    Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, Burnett R, Casey D, Coates MM, Cohen A, Delwiche K, Estep K, Frostad JJ, Astha KC, Kyu HH, Moradi-Lakeh M, Ng M, Slepak EL, Thomas BA, Wagner J, Aasvang GM, Abbafati C, Abbasoglu Ozgoren A, Abd-Allah F, Abera SF, Aboyans V, Abraham B, Abraham JP, Abubakar I, Abu-Rmeileh NM, Aburto TC, Achoki T, Adelekan A, Adofo K, Adou AK, Adsuar JC, Afshin A, Agardh EE, Al Khabouri MJ, Al Lami FH, Alam SS, Alasfoor D, Albittar MI, Alegretti MA, Aleman AV, Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Ali MK, Alla F, Allebeck P, Allen PJ, Alsharif U, Alvarez E, Alvis-Guzman N, Amankwaa AA, Amare AT, Ameh EA, Ameli O, Amini H, Ammar W, Anderson BO, Antonio CA, Anwari P, Argeseanu Cunningham S, Arnlöv J, Arsenijevic VS, Artaman A, Asghar RJ, Assadi R, Atkins LS, Atkinson C, Avila MA, Awuah B, Badawi A, Bahit MC, Bakfalouni T, Balakrishnan K, Balalla S, Balu RK, Banerjee A, Barber RM, Barker-Collo SL, Barquera S, Barregard L, Barrero LH, Barrientos-Gutierrez T, Basto-Abreu AC, Basu A, Basu S, Basulaiman MO, Batis Ruvalcaba C, Beardsley J, Bedi N, Bekele T, Bell ML, Benjet C, Bennett DA, Benzian H, Bernabé E, Beyene TJ, Bhala N, Bhalla A, Bhutta ZA, Bikbov B, Bin Abdulhak AA, Blore JD, Blyth FM, Bohensky MA, Bora Başara B, Borges G, Bornstein NM, Bose D, Boufous S, Bourne RR, Brainin M, Brazinova A, Breitborde NJ, Brenner H, Briggs AD, Broday DM, Brooks PM, Bruce NG, Brugha TS, Brunekreef B, Buchbinder R, Bui LN, Bukhman G, Bulloch AG, Burch M, Burney PG, Campos-Nonato IR, Campuzano JC, Cantoral AJ, Caravanos J, Cárdenas R, Cardis E, Carpenter DO, Caso V, Castañeda-Orjuela CA, Castro RE, Catalá-López F, Cavalleri F, Çavlin A, Chadha VK, Chang JC, Charlson FJ, Chen H, Chen W, Chen Z, Chiang PP, Chimed-Ochir O, Chowdhury R, Christophi CA, Chuang TW, Chugh SS, Cirillo M, Claßen TK, Colistro V, Colomar M, Colquhoun SM, Contreras AG, Cooper C, Cooperrider K, Cooper LT, Coresh J, Courville KJ, Criqui MH, Cuevas-Nasu L, Damsere-Derry J, Danawi H, Dandona L, Dandona R, Dargan PI, Davis A, Davitoiu DV, Dayama A, de Castro EF, De la Cruz-Góngora V, De Leo D, de Lima G, Degenhardt L, del Pozo-Cruz B, Dellavalle RP, Deribe K, Derrett S, Des Jarlais DC, Dessalegn M, deVeber GA, Devries KM, Dharmaratne SD, Dherani MK, Dicker D, Ding EL, Dokova K, Dorsey ER, Driscoll TR, Duan L, Durrani AM, Ebel BE, Ellenbogen RG, Elshrek YM, Endres M, Ermakov SP, Erskine HE, Eshrati B, Esteghamati A, Fahimi S, Faraon EJ, Farzadfar F, Fay DF, Feigin VL, Feigl AB, Fereshtehnejad SM, Ferrari AJ, Ferri CP, Flaxman AD, Fleming TD, Foigt N, Foreman KJ, Paleo UF, Franklin RC, Gabbe B, Gaffikin L, Gakidou E, Gamkrelidze A, Gankpé FG, Gansevoort RT, García-Guerra FA, Gasana E, Geleijnse JM, Gessner BD, Gething P, Gibney KB, Gillum RF, Ginawi IA, Giroud M, Giussani G, Goenka S, Goginashvili K, Gomez Dantes H, Gona P, Gonzalez de Cosio T, González-Castell D, Gotay CC, Goto A, Gouda HN, Guerrant RL, Gugnani HC, Guillemin F, Gunnell D, Gupta R, Gupta R, Gutiérrez RA, Hafezi-Nejad N, Hagan H, Hagstromer M, Halasa YA, Hamadeh RR, Hammami M, Hankey GJ, Hao Y, Harb HL, Haregu TN, Haro JM, Havmoeller R, Hay SI, Hedayati MT, Heredia-Pi IB, Hernandez L, Heuton KR, Heydarpour P, Hijar M, Hoek HW, Hoffman HJ, Hornberger JC, Hosgood HD, Hoy DG, Hsairi M, Hu G, Hu H, Huang C, Huang JJ, Hubbell BJ, Huiart L, Husseini A, Iannarone ML, Iburg KM, Idrisov BT, Ikeda N, Innos K, Inoue M, Islami F, Ismayilova S, Jacobsen KH, Jansen HA, Jarvis DL, Jassal SK, Jauregui A, Jayaraman S, Jeemon P, Jensen PN, Jha V, Jiang F, Jiang G, Jiang Y, Jonas JB, Juel K, Kan H, Kany Roseline SS, Karam NE, Karch A, Karema CK, Karthikeyan G, Kaul A, Kawakami N, Kazi DS, Kemp AH, Kengne AP, Keren A, Khader YS, Khalifa SE, Khan EA, Khang YH, Khatibzadeh S, Khonelidze I, Kieling C, Kim D, Kim S, Kim Y, Kimokoti RW, Kinfu Y, Kinge JM, Kissela BM, Kivipelto M, Knibbs LD, Knudsen AK, Kokubo Y, Kose MR, Kosen S, Kraemer A, Kravchenko M, Krishnaswami S, Kromhout H, Ku T, Kuate Defo B, Kucuk Bicer B, Kuipers EJ, Kulkarni C, Kulkarni VS, Kumar GA, Kwan GF, Lai T, Lakshmana Balaji A, Lalloo R, Lallukka T, Lam H, Lan Q, Lansingh VC, Larson HJ, Larsson A, Laryea DO, Lavados PM, Lawrynowicz AE, Leasher JL, Lee JT, Leigh J, Leung R, Levi M, Li Y, Li Y, Liang J, Liang X, Lim SS, Lindsay MP, Lipshultz SE, Liu S, Liu Y, Lloyd BK, Logroscino G, London SJ, Lopez N, Lortet-Tieulent J, Lotufo PA, Lozano R, Lunevicius R, Ma J, Ma S, Machado VM, MacIntyre MF, Magis-Rodriguez C, Mahdi AA, Majdan M, Malekzadeh R, Mangalam S, Mapoma CC, Marape M, Marcenes W, Margolis DJ, Margono C, Marks GB, Martin RV, Marzan MB, Mashal MT, Masiye F, Mason-Jones AJ, Matsushita K, Matzopoulos R, Mayosi BM, Mazorodze TT, McKay AC, McKee M, McLain A, Meaney PA, Medina C, Mehndiratta MM, Mejia-Rodriguez F, Mekonnen W, Melaku YA, Meltzer M, Memish ZA, Mendoza W, Mensah GA, Meretoja A, Mhimbira FA, Micha R, Miller TR, Mills EJ, Misganaw A, Mishra S, Mohamed Ibrahim N, Mohammad KA, Mokdad AH, Mola GL, Monasta L, Montañez Hernandez JC, Montico M, Moore AR, Morawska L, Mori R, Moschandreas J, Moturi WN, Mozaffarian D, Mueller UO, Mukaigawara M, Mullany EC, Murthy KS, Naghavi M, Nahas Z, Naheed A, Naidoo KS, Naldi L, Nand D, Nangia V, Narayan KM, Nash D, Neal B, Nejjari C, Neupane SP, Newton CR, Ngalesoni FN, Ngirabega J de D, Nguyen G, Nguyen NT, Nieuwenhuijsen MJ, Nisar MI, Nogueira JR, Nolla JM, Nolte S, Norheim OF, Norman RE, Norrving B, Nyakarahuka L, Oh IH, Ohkubo T, Olusanya BO, Omer SB, Opio JN, Orozco R, Pagcatipunan RS Jr, Pain AW, Pandian JD, Panelo CI, Papachristou C, Park EK, Parry CD, Paternina Caicedo AJ, Patten SB, Paul VK, Pavlin BI, Pearce N, Pedraza LS, Pedroza A, Pejin Stokic L, Pekericli A, Pereira DM, Perez-Padilla R, Perez-Ruiz F, Perico N, Perry SA, Pervaiz A, Pesudovs K, Peterson CB, Petzold M, Phillips MR, Phua HP, Plass D, Poenaru D, Polanczyk GV, Polinder S, Pond CD, Pope CA, Pope D, Popova S, Pourmalek F, Powles J, Prabhakaran D, Prasad NM, Qato DM, Quezada AD, Quistberg DA, Racapé L, Rafay A, Rahimi K, Rahimi-Movaghar V, Rahman SU, Raju M, Rakovac I, Rana SM, Rao M, Razavi H, Reddy KS, Refaat AH, Rehm J, Remuzzi G, Ribeiro AL, Riccio PM, Richardson L, Riederer A, Robinson M, Roca A, Rodriguez A, Rojas-Rueda D, Romieu I, Ronfani L, Room R, Roy N, Ruhago GM, Rushton L, Sabin N, Sacco RL, Saha S, Sahathevan R, Sahraian MA, Salomon JA, Salvo D, Sampson UK, Sanabria JR, Sanchez LM, Sánchez-Pimienta TG, Sanchez-Riera L, Sandar L, Santos IS, Sapkota A, Satpathy M, Saunders JE, Sawhney M, Saylan MI, Scarborough P, Schmidt JC, Schneider IJ, Schöttker B, Schwebel DC, Scott JG, Seedat S, Sepanlou SG, Serdar B, Servan-Mori EE, Shaddick G, Shahraz S, Levy TS, Shangguan S, She J, Sheikhbahaei S, Shibuya K, Shin HH, Shinohara Y, Shiri R, Shishani K, Shiue I, Sigfusdottir ID, Silberberg DH, Simard EP, Sindi S, Singh A, Singh GM, Singh JA, Skirbekk V, Sliwa K, Soljak M, Soneji S, Søreide K, Soshnikov S, Sposato LA, Sreeramareddy CT, Stapelberg NJ, Stathopoulou V, Steckling N, Stein DJ, Stein MB, Stephens N, Stöckl H, Straif K, Stroumpoulis K, Sturua L, Sunguya BF, Swaminathan S, Swaroop M, Sykes BL, Tabb KM, Takahashi K, Talongwa RT, Tandon N, Tanne D, Tanner M, Tavakkoli M, Te Ao BJ, Teixeira CM, Téllez Rojo MM, Terkawi AS, Texcalac-Sangrador JL, Thackway SV, Thomson B, Thorne-Lyman AL, Thrift AG, Thurston GD, Tillmann T, Tobollik M, Tonelli M, Topouzis F, Towbin JA, Toyoshima H, Traebert J, Tran BX, Trasande L, Trillini M, Trujillo U, Dimbuene ZT, Tsilimbaris M, Tuzcu EM, Uchendu US, Ukwaja KN, Uzun SB, van de Vijver S, Van Dingenen R, van Gool CH, van Os J, Varakin YY, Vasankari TJ, Vasconcelos AM, Vavilala MS, Veerman LJ, Velasquez-Melendez G, Venketasubramanian N, Vijayakumar L, Villalpando S, Violante FS, Vlassov VV, Vollset SE, Wagner GR, Waller SG, Wallin MT, Wan X, Wang H, Wang J, Wang L, Wang W, Wang Y, Warouw TS, Watts CH, Weichenthal S, Weiderpass E, Weintraub RG, Werdecker A, Wessells KR, Westerman R, Whiteford HA, Wilkinson JD, Williams HC, Williams TN, Woldeyohannes SM, Wolfe CD, Wong JQ, Woolf AD, Wright JL, Wurtz B, Xu G, Yan LL, Yang G, Yano Y, Ye P, Yenesew M, Yentür GK, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Younoussi Z, Yu C, Zaki ME, Zhao Y, Zheng Y, Zhou M, Zhu J, Zhu S, Zou X, Zunt JR, Lopez AD, Vos T, Murray CJ, 2015. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386: 22872323.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    UNICEF, 2012. Raising Even More Clean Hands: Advancing Health, Learning and Equity through WASH in Schools. New York, NY: UNICEF.

  • 3.

    Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, Luby S, 2007. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 76: 11661173.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Caruso BA, Freeman MC, Garn JV, Dreibelbis R, Saboori S, Muga R, Rheingans R, 2014. Assessing the impact of a school-based latrine cleaning and handwashing program on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health 19: 11851197.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Garn JV, Greene LE, Dreibelbis R, Saboori S, Rheingans RD, Freeman MC, 2013. A cluster-randomized trial assessing the impact of school water, sanitation and hygiene improvements on pupil enrolment and gender parity in enrolment. J Water Sanit Hyg Dev 3: 592601.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Freeman MC, Clasen T, Dreibelbis R, Saboori S, Greene LE, Brumback B, Muga R, Rheingans R, 2014. The impact of a school-based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster-randomized trial. Epidemiol Infect 142: 340351.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, Rheingans R, 2012. Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health 17: 380391.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Rosen L, Manor O, Engelhard D, Brody D, Rosen B, Peleg H, Meir M, Zucker D, 2006. Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools. Prev Med 42: 2732.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Trinies V, Garn JV, Chang HH, Freeman MC, 2016. The impact of a comprehensive school WASH program on absenteeism, diarrhea, and respiratory infection symptoms: a matched-control trial in Mali. Am J Trop Med Hyg 10: 14181425.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Talaat M, Afifi S, Dueger E, El-Ashry N, Marfin A, Kandeel A, Mohareb E, El-Sayed N, 2011. Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt. Emerg Infect Dis 17: 619625.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Freeman MC, Clasen T, Brooker SJ, Akoko DO, Rheingans R, 2013. The impact of a school-based hygiene, water quality and sanitation intervention on soil-transmitted helminth reinfection: a cluster-randomized trial. Am J Trop Med Hyg 89: 875883.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Greene LE, Freeman MC, Akoko D, Saboori S, Moe C, Rheingans R, 2012. Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial. Am J Trop Med Hyg 87: 385393.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Alexander KT, Robert D, Betty O, Richard R, 2013. Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster-randomized trial in western Kenya. J Water Health 11: 507519.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Garn JV, Brumback BA, Drews-Botsch CD, Lash TL, Kramer MR, Freeman MC, 2016. Estimating the effect of school water, sanitation, and hygiene improvements on pupil health outcomes. Epidemiology 27: 752760.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Brumback BA, He Z, Prasad M, Freeman MC, Rheingans R, 2014. Using structural-nested models to estimate the effect of cluster-level adherence on individual-level outcomes with a three-armed cluster-randomized trial. Stat Med 33: 14901502.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Hernan MA, Robins JM, 2006. Instruments for causal inference: an epidemiologist's dream? Epidemiology 17: 360372.

  • 17.

    Ten Have TR, Normand SL, Marcus SM, Brown CH, Lavori P, Duan N, 2008. Intent-to-treat vs. non-intent-to-treat analyses under treatment non-adherence in mental health randomized trials. Psychiatr Ann 38: 772783.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Hartung C, Anokwa Y, Brunette W, Lerer A, Tseng C, Borriello G, 2010. Open data kit: tools to build information services for developing regions. Proceedings of the 4th ACM/IEEE International Conference on Information and Communication Technologies and Development (ICTD). New York, NY.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Baqui AH, Black RE, Yunus M, Hoque AR, Chowdhury HR, Sack RB, 1991. Methodological issues in diarrhoeal diseases epidemiology: definition of diarrhoeal episodes. Int J Epidemiol 20: 10571063.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM Jr, 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 4252.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, Ahmed T, Ashraf S, Christensen G, Clasen T, Dentz HN, Fernald LCH, Haque R, Hubbard AE, Kariger P, Leontsini E, Lin A, Njenga SM, Pickering AJ, Ram PK, Tofail F, Winch PJ, Colford JM Jr, 2013. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open 3: e003476.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Carter RC, Ross I, 2016. Beyond ‘functionality’ of handpump-supplied rural water services in developing countries. Waterlines 35: 94110.

  • 23.

    Toubkiss J, Bickel S, 2016. Equity, Scalability and Sustainability in UNICEF WASH Programming: Evidence from UNICEF Evaluations 2007–2015. New York, NY: UNICEF Evaluation Office.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 430 373 29
Full Text Views 501 16 0
PDF Downloads 232 12 0
 
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save