What does the latest WASH in Schools literature say? There has been an increase in recent years on studies assessing the impact of WinS on health and education of school-age children. However, there is still a need for rigorous evidence on efficacy and effectiveness of WinS programs, specifically on the integration of WinS with other health and educational approaches consistent with the belief that WinS is foundational for creating an enabling environment for a childcentered learning environment. Most critical is the need to ensure sustained services and behavior change.

2. WASH in Schools Evidence Base: Strengths and Gaps
Contributors: Christie Chatterly, Nick Chudeau, Leslie Moreland, Peter van
Maanen, and Matthew C.Freeman
What does the latest WASH in Schools literature say?
There has been an increase in recent years on studies assessing the impact of WinS
on health and education of school-age children. However, there is still a need for
rigorous evidence on efficacy and effectiveness of WinS programs, specifically on
the integration of WinS with other health and educational approaches consistent with
the belief that WinS is foundational for creating an enabling environment for a child-
centered learning environment. Most critical is the need to ensure sustained services
and behavior change.
Does it work?
Health. There is evidence that WinS intervention can improve student health.
Studies have shown reduction in soil-transmitted helmimth infection1
, acute
respiratory illness2 3 4 5
and diarrhea5 6
. A comprehensive WASH package was
shown to improve diarrhea among the siblings of school children, but diarrhea was
not reduced for an intervention that just promoted hygiene and sanitation7
. However,
this may have been due to sub-optimal hygiene, which in the presence of higher
sanitation use may lead to health risks8
.
Education. There is evidence that WinS can improve attendance9 10 11
,particularly
for girls12
. There is some evidence that a comprehensive WASH package can
increase enrollment13
. There is (some) evidence that reducing voluntary/involuntary
dehydration in primary schools can improve pupils’ cognitive abilities14 15
. However,
there is no evidence that suggests that WinS interventions are more cost-effective in
improving educational outcomes compared to other (non wash) interventions.
Equity and Inclusion. WinS has been linked to improved equity, including reduced
time hauling water for girls16
, increased safety17
, and comfort for menstrual hygiene
management18
. While some studies are looking at access to and participation in
WASH programs by people with disabilities, little research has been done in this
area specifically for WinS19
.
Community. There is (some) evidence that pupils can also act as agents of change,
influencing their siblings and parents to change their own wash practices20
.
However, impact depends on continued access to functional WASH services and
associated behavior changes8 11. Handwashing with soap activities are known to
reinforce social interactions among school children21
and reinforce social norms
within the school community22 23
.

3. What works?
More evidence is needed to learn what it takes to sustain services and behaviors so
that impacts are realized24
. Despite this gap, there is some evidence of how to
improve service management and encourage behavior change.
Behavior change. Better maintenance and cleanliness has been associated with
higher toilet use16 25 26
. Social norms and children’s perspectives also play a large
part and formative research was used to shape programming in Senegal to
encourage more sustainable behavior change27
. Behavior change does not only
include hand hygiene, but plays an important role in changing norms around all
WinS-related behaviors such as latrine use, maintenance, water treatment, and
water storage. Our understanding of how to effectively and sustainably change
behaviors, and how to develop programs that change behavior is currently limited.
Management. Barriers to continued maintenance and provision of WinS services
have been identified in a number of countries, including a lack of incentives to
manage services, poor quality construction, and inadequate supply chain for spare
parts and services25 28 29 30
. There has been no evidence correlating the presence of
a janitor, school size, or students per toilet ratios to sanitation conditions25 29 30. The
influence of student health clubs has only been associated with higher service
maintenance when the clubs were active in WASH10 25. In general, continued
financial support for operations and maintenance has been linked with better
maintained services and should be allocated prior to intervention25 28 30. Specific to
overcoming barriers to soap provision, using soapy water has potential to be more
sustainable than bar soap in schools in Kenya31
.
How can I contribute to the evidence base on WASH in Schools?
1. Build the evidence for how WinS can be improved.
There is sufficient evidence to suggest that WinS investments are worthwhile.
However, the realization of impact depends on successful intervention where
services are functional and used by students. Research is needed to identify
effective strategies for how WinS programming can effectively and sustainably lead
to the service improvements and behavior changes required for impact. There is
insufficient knowledge of what works where and why17 29 32
. Answers to questions
such as how to encourage continued soap provision, toilet cleaning and
handwashing, are needed.
2. Evaluate the impact of exposure, not simply the impact of “intervention”.
Differences in intervention should be considered when assessing impact. The
influence of actual exposure (e.g. toilet conditions and use, handwashing) on the
outcome of interest (e.g. attendance), needs to be accounted for, rather than
assuming that assignment to an intervention group is an accurate reflection of
exposure to WinS improvements. Intermediate variables or other methods to
account for actual exposure is needed to compliment randomized controlled trials32.
These methods can also support learning how to improve WinS programming as a
component of impact studies.

4. 3. Focus on equity and Iinclusion
Issues of equity, including access to and participation in WinS by all girls, boys and
female and male teaching staff, including those with disabilities, need to be
considered. While some research has been undertaken about how to construct more
inclusive WASH facilities to meet the demands of people with disabilities and to
make facilities more gender sensitive, little evidence is available about how these
issues can be applied in a WinS context33
. There is also little evidence regarding the
cost-effectiveness of inclusive facilities. More work in this area is needed in order to
determine how to best design inclusive WinS programming and to determine the
cost effectiveness of such approaches.
Future studies should also disaggregate outcomes by gender and state, for example,
if toilets are gender segregated34
. Qualitative studies are needed to investigate both
boys’ and girls’ perspectives, such as girls’ views on gender-segregated toilets, as
well as to identify the demand driven barriers for girls and boys in accessing and
using WASH facilities. Barriers to behavior change, such as handwashing, may differ
by gender and research should account for these differences to improve intervention
that reaches both boys and girls.
4. Learn what’s important to students, and teachers to encourage behavior
change
If WinS services are not acceptable to students or hygiene education doesn’t
consider student priorities, student behavior change is unlikely. It is also important to
understand the perspectives and needs of teaching staff as they can lead by
example and often wield influence over WASH-based decisions and sustaining
change. Lessons from the private sector, such as consumer research and formative
research35
, could inform programming improvements so that services are used by
students. These findings need to be context specific.
5. Share evidence and lessons-learned
There is often little or no systematic documentation of achievements and failures, or
dissemination of unbiased lessons learned32. Research does not have to be a highly
specialized endeavor reserved for academic institutions and peer-reviewed journals.
However, it does need to be rigorous. Programs and implementers should develop
rigorous documentation of best practices and lessons learned within local and
regional networks. The SWASH+ program in Kenya provides an example of
dissemination of information through informal documentation of lessons-learned as
well as peer-reviewed publications, where both types of literature have informed
sector improvements.
6. Build on inter-sectoral collaboration
Integration of WASH interventions with other health and education focused
initiatives, such as nutrition based programming and elimination of neglected tropical
diseases (NTDs), may improve overall health and education outcomes.
Collaboration between disease control programs and stakeholders in WASH is a
critical next step36
. More work is needed to build a strong evidence-base for
collaborative programming (with education, nutrition, and other sectors) and to
determine if and what collaborations are most effective.
*

5. ********************************************************
1
Freeman, M. C., Clasen, T., Brooker, S. J., Akoko, D. O., & Rheingans, R. (2013) The Impact of a School-
2
Patel MK, Harris JR, Juliao P, Nygren B, Were V, Kola S, Sadumah I, Faith SH, Otieno R, Obure A,
Hoekstra RM, Quick R. (2012) Impact of a Hygiene Curriculum and the Installation of Simple Handwashing
and Drinking Water Stations in Rural Kenyan Primary Schools on Student Health and Hygiene Practices.
Am J Trop Med Hyg. 87(4):594–601.
3
Lopez-Quintero C, Paul F, Neumark Y. (2009) Hand Washing Among School Children in Bogotá,
Colombia. Am J Public Health. 99(1):94-101.
4
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. 17:619–625.
5
Freeman MC, Clasen T, Dreibelbis R, Greene LE, Saboori S, Brumback B, Muga R, Rheingans R. (2013)
The impact of a school-based water supply and treatment, hygiene, and sanitation programme on pupil
diarrhoea: A cluster-randomized trial. Epi Infection. (2013) 1-12. doi:10.1017/S0950268813001118
6
Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. (2013) The impact of school-based
water, sanitation, and hygiene improvements on diarrhea and clinic visits among young siblings of school-
going children: results from a cluster-randomized trial. AJPH. Epub ahead of print:
doi: 10.2105/AJPH.2013.301412
7
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. 76:1166-1173.
8
Greene L, Freeman MC, Akoko D, Saboori S, Moe C, Rheingans R: Impact of a school-based hygiene
promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized
trial. American Journal of Tropical Medicine and Hygiene 2012, 87:385-393.
9
Blanton E, Ombeki S, Oluoch GO, Mwaki A, Wannemuehler K, Quick R. (2010) Evaluation of the role of
school children in the promotion of point-of-use water treatment and handwashing in schools and
households-Nyanza province, Western Kenya, 2007. Am. J. Trop. Med. Hyg. 82:664–671.
10
Njuguna V, Karanja B, Thuranira M, Shordt K, Snel M, Cairncross S: The Sustainability and Impact of
School Sanitation, Water and Hygiene Education in Kenya. United Nations Children’s Fund and IRC
International Water and Sanitation Centre; 2008
11
O’Reilly CE, Freeman MC, Ravani M, Migele J, Mwaki A, Ayalo M. (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. Epidemiology and Infection. 136:80-91.
12
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(3):380-391.
13
Garn J, Greene LE, Dreibelbis R, Saboori S, Rheingans R, Freeman MC. (2013) A cluster-randomized
trial assessing the impact of school water, sanitation, and hygiene improvements on pupil enrollment and
gender parity in enrollment. J WASH for Development. In press. doi:10.2166/washdev.2013.217
14
Edmonds, Caroline J., and Denise Burford, ‘Should Children Drink More Water? The effects of drinking
water on cognition in children’, Appetite, vol. 52, no. 3, June 2009, pp. 776–779;
15
Fadda, R., et al., ‘Effects of Drinking Supplementary Water at School on Cognitive Performance in
Children’, Appetite, vol. 59, no. 3, December 2012, pp. 730–737.
16
Nauges C, Strand J. (2011) Water Hauling and Girls’ School Attendance: Some new evidence from
Ghana. World Bank. p.25.

6. *********************************************************************************************************************************************************************
17
Pearson J, McPhedran K. (2008) A Literature Review of the Non-Health Impacts of Sanitation. Waterlines.
27(1):48–61.
18
http://www.unicef.org/wash/schools/files/WASH_in_Schools_Empowers_Girls_Education_Proceedings_of_
Virtual_MHM_conference.pdf
19
Erhard L*, DeGabriele J, Naughton, D, Freeman MC. (2013). Policy and provision of WASH in schools for
children with disabilities: A case study in Malawi and Uganda. Global Public Health. Epub ahead of print.
8(9) doi: 10.1080/17441692.2013.838284
20
For example, see
• Onyango-Ouma, W., J. Aagaard-Hansen, and B.B. Jensen. 2005. “The potential of schoolchildren
as health change agents in rural western Kenya.” Social Science & Medicine 61, no. 8 (October
2005): 1711-1722
• O’REILLY, C. E., M. C. FREEMAN, M. RAVANI, J. MIGELE, A. MWAKI, M. AYALO, S. OMBEKI,
R. M. HOEKSTRA, and R. QUICK. “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.” Epidemiology and Infection 136, no. 1 (January 2008): 80-91.
• Pinfold JV (1999) Analysis of different communication channels for promoting hygiene behaviour.
Health Education Research 14, 629–639.
• Dongre, A.R.; Deshmukh, P.R.; Boratne, A.V.; Thaware, P. and Garg, B.S. (2007) An approach to
hygiene education among rural Indian school going children. Online Journal of Health and Allied
Sciences, 6 (4). ISSN 0972-5997
• Curtis, V., B. Kanki, S. Cousens, I. Diallo, A. Kpozehouen, M. Sangaré, and M. Nikiema. 2001.
“Evidence of behaviour change following a hygiene promotion programme in Burkina Faso.”
Bulletin of the World Health Organization 79, no. 6 (2001): 518-527
21
Dutton, Peschiera, & Nguyen. (2011). The power of primary schools to change and sustain handwashing
with soap among children: The cases of Vietnam and Peru.
http://www.wsp.org/sites/wsp.org/files/publications/WSP-handwashing-schools-vietnam-peru.pdf
22
Chittleborough, Nicholson, Basker, Bell, Campbell (2012). Factors influencing hand washing behavior in
primary schools: process evaluation within a randomized controlled trial. Health Education Research. 1-14.
23
Xuan, Rheinlander, Hoat, Dalsagaard, & Konradsen. (2013). Teaching handwashing with soap for
schoolchildren in a multi-ethnic population in northern rural Vietnam. Glob Health Action 6: 20288.
http://www.ncbi.nlm.nih.gov/pubmed/23618342
24
Carter R. (2013) Editorial: researching ‘how’ rather than ‘why’. Waterlines. 32(1):3-4
25
Mathew K, Zachariah S, Shordt K, Snel M, Cairncross S, Biran A, Schmidt W. (2009) The sustainability
and impact of school sanitation, water and hygiene education in southern India. Waterlines. 28.
26
Dreibelbis R, Greene LE, Freeman MC, Saboori S, Chase RP, Rheingans R. (2013) Water, sanitation,
and primary school attendance: A multi-level assessment of determinants of household-reported absence
in Kenya. Int J Educ Dev. 33(5):457-465.
27
Sidibe M, Curtis V. (2007) Can hygiene be cool and fun? Insights from school children in Senegal. Nairobi:
World Bank Water and Sanitation Program (WSP).
28
Saboori S, Mwaki A, Porter SE, Okech B, Freeman MC, Rheingans RD. (2011) Sustaining school hand
washing and water treatment programmes: lessons learned and to be learned. Waterlines, 30(4), 298-311.
29
Chatterley C, Linden KG, Javernick-Will A (2013) Identifying drivers of sustainable school sanitation in
Belize. Journal of Water, Sanitation and Hygiene for Develoment. doi:10.2166/washdev.2013.128.
30
Chatterley C, Javernick-Will A, Linden KG, Alam K, Bottinelli L, Venkatesh M. A qualitative comparative
analysis of well-managed school sanitation in Bangladesh In review.

7. *********************************************************************************************************************************************************************
31
Saboori, S., Mwaki, A., & Rheingans, R. D. (2010). Is soapy water a viable solution for handwashing in
schools? Waterlines, 29(4), 329-336.
32
DFID. (2013) Water, Sanitation and Hygiene: Evidence paper. UK Department for International
Development
33
WaterAid Australia (2012). Towards Inclusive WASH: Sharing evidence and experience from the field.
www.inclusivewash.org.au/case-studies
34
Birdthistle I, Dickson K, Freeman M, Javidi L. (2011) What is the impact of separate toilets for girls at
schools on girls’ educational outcomes? A systematic review of the evidence. MARCH Centre at LSHTM
and EPPI-Centre, University of London.
35
Sidibe M, Curtis V. (2007) Can hygiene be cool and fun? Insights from school children in Senegal. Nairobi:
World Bank Water and Sanitation Program (WSP).
36
Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, et al. (2013) Integration of Water, Sanitation,
and Hygiene for the Prevention and Control of Neglected Tropical Diseases: A Rationale for Inter- Sectoral
Collaboration. PLoS Negl Trop Dis 7(9): e2439. doi:10.1371/journal.pntd.0002439
*