Journal Article

School water, sanitation, and hygiene (WaSH) intervention to improve malnutrition, dehydration, health literacy, and handwashing: a cluster-randomised controlled trial in Metro Manila, Philippines

Ocaña, Roezel Mari Z., Borgemeister, Christian, Kistemann, Thomas, Olaguera, Mikaela, Ottong, Zheina J., Canja, Rovin James F., Cumagun, Ma. Lourdes, Prado, Nelissa O., Mariano, Shyrill Mae F., Singson, Patricia Andrea A., Anglo, Maria Vianca Jasmin C., Sangalang, Stephanie O., Lemence, Allen Lemuel G., Valencia, John Cedrick, Liao, Janine

2022

Overview

Background The impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children’s health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children’s malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines. Methods The trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children’s physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects. Results None of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal. Conclusion Increasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed. Trial registration number DRKS00021623.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Absenteeism / Academic achievement / Anthropometry / Biostatistics / Body mass index / Body size / Child / Child malnutrition / Children / Clinical trials / Clusters / Costs / Cross-sectional studies / Dehydration / Dehydration (Physiology) / Dehydration - epidemiology / Dehydration - prevention & control / Education / Environmental Health / Epidemiology / Evaluation / GDP / Gross Domestic Product / Growth Disorders - epidemiology / Hand Disinfection / Hand washing / Health aspects / Health education / Health Literacy / Heat affected zone / Humans / Hydration / Hygiene / Infectious diseases / Intervention / Malnutrition / Malnutrition - epidemiology / Malnutrition in children / Management / Medicine / Medicine & Public Health / Overnutrition / Overnutrition - epidemiology / Philippines - epidemiology / Prevention / Public Health / Public schools / Regression analysis / Regression models / Risk factors / Sanitation / School principals / School safety / Schools / Student retention / Undernutrition / Vaccine / Water / Water Supply / Workshops