Swash+ research presentation care 2011
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power point presentation on the research findings of SWASH+ in Kenya
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Swash+ research presentation care 2011
- 1. School Water, Sanitation and Hygiene: Myths Proved and Disproved 9 August 2011, CARE USA Headquarters Presenters: Malaika Wright, Shadi Saboori & Brooks Keene
- 2. School Water, Sanitation and Hygiene: Myths Proved and Disproved SWASH+: Basic Facts • What: SWASH+ is a five-year applied research project started in 2006 • Goal: To identify, develop, and test innovative approaches to school- based water, sanitation and hygiene in Nyanza Province, Kenya • Partners: CARE, Emory University, the Great Lakes University of Kisumu, the Government of Kenya, the Kenya Water for Health Organisation (KWAHO), and Water.org (formerly Water Partners International) • Where: Research and implementation conducted in Nyanza Province, Kenya
- 3. School Water, Sanitation and Hygiene: Myths Proved and Disproved Why School WASH? • At baseline, approximately 49% of schools provided drinking water to pupils • Only 11% provided water for handwashing. • In schools selected, there were 79.5 pupils per latrine on average (GoK ratios are 25:1 for girls, 30:1 for boys)
- 4. School Water, Sanitation and Hygiene: Myths Proved and Disproved The Three Components Of SWASH+ • 1) Direct implementation 2) Research 3) Advocacy/ collaborative learning Direct implementation Research • Direct implementation and research were started first • Advocacy and collaborative learning were incorporated later Advocacy/Collaborative Learning
- 5. School Water, Sanitation and Hygiene: Myths Proved and Disproved The Research Context • Widely acknowledged need for school WASH investments • Yet scant evidence base for impact • Evidence necessary to justify allocation of scarce resources • Myth vs. fact
- 6. School Water, Sanitation and Hygiene: Myths Proved and Disproved Background and Methods • Cluster randomized trial: 2007-2009 • Base package (45 schools): – Hygiene promotion + Water Treatment • Base package + Sanitation (45 schools): – HP+ WT + Sanitation • Water package (25 schools): – HP+ WT + Sanitation+ Water • Control (70 schools) – to receive improvements in third year of project
- 7. School Water, Sanitation and Hygiene: Myths Proved and Disproved
- 8. School Water, Sanitation and Hygiene: Myths Proved and Disproved 1. Does school water, sanitation and hygiene (WASH) interventions make a difference in educational achievement? 2. Which kids benefit more from school WASH? 3. Can school WASH do more harm than good? 4. What types of investments in school WASH yield the most returns?
- 9. School Water, Sanitation and Hygiene: Myths Proved and Disproved 1. Does school water, sanitation and hygiene (WASH) interventions make a difference in educational achievement? 2. Which kids benefit more from school WASH? 3. Can school WASH do more harm than good? 4. What types of investments in school WASH yield the most returns?
- 10. School Water, Sanitation and Hygiene: Myths Proved and Disproved •Significant reduction for HW+WT (OR=0.43) and HW, WT+San (OR=0.47) •Six days less absence per year for girls •No effect for boys
- 11. School Water, Sanitation and Hygiene: Myths Proved and Disproved 1. Does school water, sanitation and hygiene (WASH) interventions make a difference in educational achievement? 2. Which kids benefit more from school WASH? 3. Can school WASH do more harm than good? 4. What types of investments in school WASH yield the most returns?
- 12. School Water, Sanitation and Hygiene: Myths Proved and Disproved
- 13. School Water, Sanitation and Hygiene: Myths Proved and Disproved Effect of WASH Helminth Re-infection • Followed re-infection rates for Ascaris, Trichuris and Hookworm • Ascaris – 45% reduction in odds overall; even greater among girls • Trichuris – No effects • Hookworm – Significant reduction in intensity of infection for boys
- 14. School Water, Sanitation and Hygiene: Myths Proved and Disproved 1. Does school water, sanitation and hygiene (WASH) interventions make a difference in educational achievement? 2. Which kids benefit more from school WASH? 3. Can school WASH do more harm than good? 4. What types of investments in school WASH yield the most returns?
- 15. School Water, Sanitation and Hygiene: Myths Proved and Disproved What if key WASH components are missing? Hand Contamination •Hand Rinse: sampled pupils’ hands for fecal contamination •Measured for E. coli •Compared intervention and control schools
- 16. School Water, Sanitation and Hygiene: Myths Proved and Disproved
- 17. School Water, Sanitation and Hygiene: Myths Proved and Disproved What happened?
- 18. School Water, Sanitation and Hygiene: Myths Proved and Disproved 1. Does school water, sanitation and hygiene (WASH) interventions make a difference in educational achievement? 2. Which kids benefit more from school WASH? 3. Can school WASH do more harm than good? 4. What types of investments in school WASH yield the most returns?
- 19. School Water, Sanitation and Hygiene: Myths Proved and Disproved Reduction in Diarrheal Disease •Water Package schools showed a 66% reduction in diarrheal disease and days of illness. •This result was not gender specific. •There was no effect seen for the Base and Base + Sanitation schools.
- 20. School Water, Sanitation and Hygiene: Myths Proved and Disproved Reduction in Girls’ Absenteeism •Significant reduction in girls’ absenteeism in schools where hand washing and treated drinking water were present (irrespective of sanitation improvement) •Software components must not be overlooked •Vital recurrent costs (i.e. soap, water treatment products) must be regularly budgeted and provided in order to ensure sustainability of WASH services
- 21. School Water, Sanitation and Hygiene: Myths Proved and Disproved
- 22. School Water, Sanitation and Hygiene: Myths Proved and Disproved
- 23. School Water, Sanitation and Hygiene: Myths Proved and Disproved •2008 provision of soap = over 30% of schools •2010 provision of soap = under 8%
- 24. School Water, Sanitation and Hygiene: Myths Proved and Disproved Sustainability Successes WASH components not requiring expenditures by schools are still sustained in a majority of intervention schools (nearly 3 yrs after implementation) Sustainability Challenges WASH components requiring expenditure by schools decreased dramatically (nearly 3 yrs after implementation)
- 25. Using the Evidence and Learning: Advocacy
- 26. The policy environment • Current and planned investments in school WASH • Interested development partners • Many policies • Low capacity for implementing them • Corruption in the Ministry of Education
- 27. Specific Policy Goals 1. Increase O&M Funding $3.30/pupil/year 2. Improve M&E Downward, decentralized and supportive 3. Knowledge and behavior New curriculum (co-developed with CDC)
- 28. An inside player Independent Outside Expert research MOE investments in school WASH MOE investments in school WASH Collaborative Inside learning and learning capacity partner building
- 29. Advocacy Activities • Learning presentations • Sign-on letters with other civil society • Media work • Submitted policy briefs • Sustainability charter • Day to day badgering • International level: publishing in academic journals, issuing briefing notes and presenting at relevant fora
- 30. Measuring Our Progress: Outcome Mapping Boundary Partners Primary actors
- 31. Results to Date • $3.4 million allocated for sanitary pads for school girls this year • Piloting and openness to new M&E systems, including agreement on need for unified monitoring tool between ministries • Doubling of funds for school WASH ($840,000/year) with potentially more to come • Adoption of WASH curriculum and materials for in-service teacher training • Agreement to develop a school WASH sustainability charter • International level – Uncertain impact
- 32. Thoughts on the Process • Evidence-based advocacy works • Getting to scale through learning + advocacy (not direct service delivery) • Trying to do implementation, rigorous learning and advocacy simultaneously is hard (not necessary?) • Can’t be internally-focused • In-country policy staff are essential
Notas do Editor
- Myth vs. fact: managing purpose-driven learning – We started out knowing the impacts we would like to prove to be true because we had pre-determined advocacy objectives. However, there were surprises along the way, validating the need to take a learning approach that is as objective as possible and being forthcoming about the findings. What we’ll present next is what we’ve learned as far as validating (or invalidating) some of the common assumptions around school WASH and trying to answer some of the more perplexing questions.
- Base Package included:Water treatment, health clubs, handwashing education and materials. Emphasizes water treatment with WaterGuard (dilute sodium hypochlorite solution marketed by Population Services International) and other methods.Base Package + Sanitation included:All of the base package materials and training as well as provision of ventilated improved pit latrines.Water Package included:All of the base and sanitation package materials as well as water improvement. Water improvement consisted of either a new borehole in or nearby the school for school and community use or, if ground water feasibility studies showed poor groundwater potential, large rain water harvesting tanks were built in the school compound.
- This is a map of the study area. The study took place in 4 districts in Nyanza Province, Western Kenya: Kisumu, Nyando, Rachuonyo, and Suba.
- We used pupils’ 2 week recall pre and post intervention to measure absenteeism pre and post intervention.Potential questions from audience: 1: What about water package schools? No reduction at all? 2. What about Kisumu/Nyando district, why did we not see significant reductions? 3. Why is the effect only seen in girls?
- Female pupils in the poorest wealth quintile benefit the most. Potential questions from the audience: 1. How was this finding measured? 2. Just because this finding shows that poor girls are more likely to miss school, how are we able to assume the SWASH+ WASH interventions were particularly reaching these poor girls? Perhaps they are missing school due to taking care of a sick family member, etc. If more detail requested:By wealth group, absence rose from 16.0% among wealthiest children to 21.4% in children from the poorest household wealth group (OR: 1.48, 95% CI; 1.15 – 1.90). When the combined effect of both household wealth and gender are considered, increases in recent absence among boys ranged from 15.0% – 19.4% across wealth groups and 17.1% - 23.7% among girls.
- We collected and measured stool samples from a smaller subset of our trial schools. In coordination with the Ministry of Health, we helped to coordinate and distribute deworming medicine to all trial schools, including control schools. After a period of 6 months (need to confirm this timeline), we collected and measured stool samples to measure for Helminth re-infection. The results showed…..(see slide).Potential questions from audience: 1. Why did we see Ascaris reduction even greater among girls? 2. Why no effect in Trichuris? 3. Why did we see significant reduction in intensity of infection for boys only (not girls)?
- This was conducted in a sub-set of our trial schools.
- Finding: The hygiene promotion and water treatment intervention arm did not reduce risk of E. coli presence (RR = 0.98; 95% CI = 0.60, 1.58), and the addition of new latrines to this intervention introduced a greater risk (RR = 1.87; 95% CI = 1.01, 3.46). Efforts to increase the usage of school latrines may pose a risk to children in absence of actual hygiene behavior change and daily provision of soap and water. Possible explanations and implications are discussed, and further study is recommended.Potential thoughts on why this may have occurred: These findings suggest a lack of sufficient improvement in hand washing behavior in intervention schools coupled with an undetermined source of increased contamination risk in Sanitation schools. The small number of Sanitation schools limits our power to detect the impact of this individual intervention; however, the high magnitude of the effect cannot be ignored. One thought is that the addition of new latrines in the sanitation schools made it more likely that pupils in those schools would use the latrines more frequently for defecation but that proper hand washing behavior was not followed. Additionally, anal cleansing materials were virtually non existent in most Kenyan school settings and were not provided as part of the intervention, which would allow further opportunity for contamination.Strategies to address this further: Latrine Cleaning and Hand Washing Trial: providing cleaning supplies for latrine cleanliness, toilet paper for anal cleansing, and powdered soap to create soapy water for hand washing, observing hand washing behavior periodically, and measuring hand rinse from a subset of schools.Potential questions from the audience: 1. Why were a subset of water schools not included in this sample?
- Period prevalence of diarrhoea and duration of diarrhoeal episodes was assessed via pupil self-report for the one week prior to data collection. The case definition of diarrhoea was three or more loose or watery stools over a 24-hour period (Baqui et al., 1991). We found strong evidence among schools in the water “scarce” group that provision of a comprehensive school-based WASH intervention was effective in reducing the risk of diarrhoeal diseases. The 66% reduction overall was similar to the protection accorded both boys and girls. On the other hand, we found no evidence that the interventions without water supply improvements reduced diarrhoea. Potential questions from audience: 1. Why did we not see this result in the other packages?
- We believe that in addition to the necessary hardware components such as water improvement and sanitation infrastructure, greater attention and investment should be channeled towards software components such as hand washing, and latrine use behavior coupled with ensuring a system is in place for vital recurrent costs such as soap provision, anal cleansing materials, and water treatment products.