Research Article: Impact of a School-Based Hygiene Promotion and Sanitation Intervention on Pupil Hand Contamination in Western Kenya: A Cluster Randomized Trial

Date Published: September 05, 2012

Publisher: The American Society of Tropical Medicine and Hygiene

Author(s): Leslie E. Greene, Matthew C. Freeman, Daniel Akoko, Shadi Saboori, Christine Moe, Richard Rheingans.


Handwashing with soap effectively reduces exposure to diarrhea-causing pathogens. Interventions to improve hygiene and sanitation conditions in schools within low-income countries have gained increased attention; however, their impact on schoolchildren’s exposure to fecal pathogens has not been established. Our trial examined whether a school-based water, sanitation, and hygiene intervention reduced Escherichia coli contamination on pupils’ hands in western Kenya. A hygiene promotion and water treatment intervention did not reduce risk of E. coli presence (relative risk [RR] = 0.92, 95% confidence interval [CI] = 0.54–1.56); the addition of new latrines to intervention schools significantly increased risk among girls (RR = 2.63, 95% CI = 1.29–5.34), with a non-significant increase among boys (RR = 1.36, 95% CI = 0.74–2.49). Efforts to increase usage of school latrines by constructing new facilities may pose a risk to children in the absence of sufficient hygiene behavior change, daily provision of soap and water, and anal cleansing materials.

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Globally, ∼1.3 million children under 5 years of age die each year due to diarrhea.1 This preventable illness is the leading cause of mortality in this age group in Africa.2 Handwashing with soap can reduce the risk of diarrhea by 42–48%3 and has been shown to effectively reduce pathogens of fecal origin on hands.4,5 Despite efforts to improve handwashing at key times to prevent fecal pathogen ingestion, studies from 13 low-income countries found that only 17% of child caregivers wash their hands with soap after defecation.6

Of the 17 intervention schools randomly selected for the study, 12 were in the HP&WT study arm, whereas five were in the Sanitation + HP&WT arm. At baseline and follow-up, we obtained 707 and 695 hand rinse samples, respectively, from 34 schools. Excluded were those for which negative control samples suggested possible laboratory-derived contamination of a batch (N = 20 baseline samples), those in which background or atypical growth rendered contamination counts unreliable (N = 46 at baseline; 11 at follow-up), and those that could not be matched to a pupil survey (N = 67 at baseline; 32 at follow-up). This resulted in a total of 574 baseline and 652 follow-up hand rinse samples from 34 schools.

Our study found that an intervention consisting of school-based hygiene promotion and water treatment did not impact pupils’ risk of having E. coli hand contamination. However, girls had a significantly increased risk of having high levels of E. coli contamination on their hands. The addition of new sanitation facilities to the HP&WT intervention greatly increased children’s risk of having any E. coli and high levels of E. coli on their hands. This effect was significant and of the highest magnitude among girls. These findings suggest a lack of sufficient improvement in handwashing behavior in intervention schools coupled with an undetermined source of increased contamination risk in Sanitation + HP&WT schools.

We found no reduction in hand contamination in intervention schools as originally hypothesized. We did, however, find a dramatic increase in hand contamination among children in the Sanitation + HP &WT schools. Though the mechanism for these findings is not certain, our results suggest that efforts to increase the quantity of school latrines may pose a risk to children in absence of actual hygiene behavior change, daily provision of soap and water prior to children’s arrival at school, and provision of anal cleansing materials to prevent hand contamination. In Kenya and other countries, the sustainability of soap in schools is a challenge and has been attributed to insufficient funds, lack of motivation from teachers, or unclear roles and responsibilities.11,13,15,41 Approaches that overcome these barriers are needed as a first step to improve school hygiene. The effectiveness of various behavior change education strategies for schoolchildren should also be evaluated in future studies. Research that combines objective hand rinse data with observation methods is needed to more closely examine the relationship between actual latrine usage, handwashing behavior, and hand contamination. Potential gender differences in sanitation and hygiene behaviors need to be better understood so that WASH intervention strategies can be appropriately developed to address the unique needs of both girls and boys. Future WASH intervention trials should attempt to better understand the specific mechanisms by which school attendance is impacted, as assumptions about disease reduction may not hold. In addition, our findings point to a need for increased attention to the role that anal cleansing materials may play in the prevention of hand contamination. This topic has been largely ignored in school WASH programs. Finally, studies that assess the impact of surface cleaning in schools in low-income settings are needed. In light of the growing global push for improving sanitation coverage in schools, our findings should be carefully considered and explored further.




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