1. Impact of Simple Handwashing & Drinking Water Stations and Hygiene Education on Student Hygiene Practices & Health in Kenyan Primary Schools Saduma Iphreem Ibrahim Safe Water and Aids Project – Kisumu Kenya

2. Diarrheal diseases cause 1.34 million deaths globally per year –Most occur among children <5 years old in developing countries Important contributors to diarrhea risks include: –Lack of access to improved water –Poor hygiene Proven strategies to prevent diarrheal disease in resource- poor settings include: –Point-of-use water treatment –Handwashing with soap Promising approach to implement these strategies –School-based water treatment and hygiene programs Background

3. Students learn new habits that can last a lifetime Healthy students miss less school and learn more Children can transmit lessons to parents Rationale for School-Based Implementation

4. Increase in water treatment and handwashing knowledge* Decreased diarrhea rates** Decreased absenteeism* *O’Reilly, et al. Epidemiology Infect 2007; doi:10.1017/S0950268807008060 * Blanton, et al. AJTMH 2010.; 82(4), 2010, pp. 664–671 **Migele, et al. AJTMH 2007; 76(2), 2007, pp. 351–353 Results of Previous School Programs in Western Kenya

5. Nyando Integrated Child Health and Education Project (NICHE) Purpose: Increase access to health information, water treatment products, safe water storage containers, soap, and other interventions Approach: Integrated implementation Social marketing Health promotion and product sales by HIV self-help groups organized by the Safe Water and AIDS Project (SWAP) Installation of water stations in schools and clinics Health promotion by teachers and health workers

6. Nyanza Province, Kenya Nyando Division L. Victoria NYANZA PROVINCE (Pop. 80,000)

7. Objective Determine impact of the NICHE school program on pupils’ hand washing knowledge and health

8. Methods Two-stage cluster sampling strategy –First stage: village level Intervention group: 30 villages Comparison group: 30 villages Probability of selection proportional to size –Second stage: household level Census of 60 study villages Random sample of households with a child <3yo School selection –Intervention schools (n=21): located in intervention villages –Comparison schools (n=22): located in comparison villages Pupil selection –All pupils in grades 4-8 living in households selected for study

9. Baseline Data Collection (March 2007) Pupil interviews –Reported hand washing at school –Ability to demonstrate proper hand-washing technique Caregiver interviews –Demographic & SES −Reported HH illnesses

10. Implementation of Intervention Intervention schools (April-May 2007): Teacher training: hand washing and water treatment Instruction materials for students Hand washing stations: installed near latrines –60 liter plastic buckets with lids and taps –Metal stands –3-month “starter” supply of soap Drinking water stations: installed near classrooms –60 liter plastic buckets with lids and taps –Metal stands –3-month supply of WaterGuard Comparison schools (April-May 2008)

11. Evaluation Timeline March 2007 Baseline Mar 2008 April 2007 Bi-Wkly active Surveillance Year 1 Implementation Intervention schools Follow-up 1 Bi-Wkly active Surveillance Year 2 April 2008 Follow-up 2 Implementation Comparison schools Mar 2009

12. Data Analysis Data are presented as school level aggregates: –Medians (interquartile range 25-75%) To compare pupil responses between intervention and comparison schools, we estimated differences in medians (EDM) –Calculated for each cross sectional survey –Represent an estimated effect size –Because of small number of schools, we report 90% confidence intervals (CI) –Differences are considered significant if the CI does not cross zero EDM is also used to compare active surveillance data –For each year of surveillance, data were aggregated at school level –Median illness rates compared between intervention and comparison schools

13. RESULTS

14. Study Population 378 students 262 students 187 students 405 students 216 students 140 students InterventionComparison 116 students lost to follow-up 189 students lost to follow-up 76 students lost to follow-up 75 students lost to follow-up Baseline Follow-up 1 Follow-up 2

15. Baseline Characteristics Median % of female HH caregivers 100 (94--100), Age 37 (30--45) <1% have electricity 75% live in 1 room homes 97% have mud walls 60% have iron roofs 48% drink surface water

16. Median Percentage of Pupils Reporting Hand Washing at School and Demonstrating Proper Hand Washing Technique BASELINE (2007) FOLLOW UP YEAR 1 (2008) FOLLOW UP YEAR 2 (2009) Behavior INT (range) COMP (range) EDM (90% CI) INT (range) COMP (range) EDM (90% CI) INT (range) COMP (range) EDM (90% CI) Reported washing Hands While at school 76 (42- 88) 56 (38- 72) 23 (3-39) 100 (93- 100) 40 (25- 54) 60 (53-73)100 0 Showed Proper HW skills 31 (25- 48) 32 (14- 42) 4 (-11- 19) 46 (30- 75) 14 (0- 33) 32 (10-46) 54 (33- 100) 50 (31- 75) 0 (-17- 11)

17. Median Percentage of Caregivers Reporting Pupil Illness During Active Surveillance Visits YEAR 1YEAR 2 INT (range) COMP (range) EDM (90% CI) INT (range) COMP (range) EDM (90% CI) Any illness5 (4-7)7 (6-9)-3 (-4- -1)3 (2-3)2 (1-3)1 (-1-1) Diarrhea 0 (0-0.3)0.3 (0-0.6)0 (0-0) Acute respiratory Illness 2 (1-4)3 (3-6)-2 (-3- -1)0.8 (0-1.5)0.7 (0.3-1.5)1 (-1-1)

18. Limitations Illness outcomes were reported and not clinically confirmed Biweekly home visits could have resulted in respondent fatigue and lowered rates of reported illness High pupil loss to follow-up through graduation and dropping out Results not generalizable

19. Conclusions School-based hygiene intervention appeared to reduce the risk of overall reported illness and respiratory infections –Lower rates in pupils in intervention schools in year 1 –Similar rates in both groups in year 2 after implementation of intervention in comparison schools School-based hygiene intervention appeared to improve handwashing behavior –Higher reported handwashing in school and ability to demonstrate proper hygiene technique among intervention pupils in year 1 –Similar rates in both groups in year 2

20. Acknowledgements CDC Minal K. Patel Julie R. Harris Patricia Juliao Benjamin Nygren Robert Quick SWAP Alie Eleveld NICHE-Kenya Team Vincent Were Steve Kola Sitnah Hamidah Faith Ronald Otieno Ministry of Education School Teachers sadumah@swapkenya.org www.swapkenya.org

21. Thank You!