Effectiveness of Water, Sanitation and Hygiene (WASH) Intervention for School going Children on Hygiene Practices, Absenteeism, Diarrhea, and Respiratory Infection: An Interventional Study Protocol

Introduction: Safe drinking water, sanitation and hygiene beyond the household, and particularly in the school setting, are crucial to the health and education of children. Ashram schools where children from tribal community are taking education in India are mostly ignored. Thus, inclusion of water, sanitation and hygiene (WASH) in schools as part of the SDG, necessitates assessing the coverage and utilization in all types of schools; Government, private, funded including Ashram (residential) schools. Hence, we plan this research to study the effectiveness of proposed WASH in Ashram school with regards to hygiene practices, diarrheal diseases, respiratory infection and school absenteeism. Methods: Interventional study will be conducted in all eight Ashram schools of Wardha district. Baseline data regarding WASH practices and absenteeism, diarrhea, and respiratory infection will Study Protocol Dakhode and Gaidhane; JPRI, 33(54A): 77-87, 2021; Article no.JPRI.78324 78 be collected. Intervention model for adopting safe WASH practices will be developed implemented in randomly selected four ashram schools. Survey and interview questionnaire will be adopted from UNICEF monitoring package modules. Children of forth, fifth and sixth classes (460), teachers, and Principles(8) will be interviewed; and school environment will be reviewed. After collection of post intervention data in ODK tool, descriptive statistics, two-sample t-tests and unadjusted mean percentages for all outcome variables were calculated by aggregating individual-level data to the school level. Conclusion: The intervention package is based on community mobilization and participation; life skill education, capacity building of school staff related to WASH. This will contribute to bring long term changes and improvement in health status and academic performance of school children.


INTRODUCTION
Undernutrition, anaemia and parasitic infections were strongly associated with poor water sanitation and hygiene practices among school going children of 8-14 years. [1] Children spend a major portion of their day at school where they come across water sanitation and hygiene practices. Here is beginning of their attitude and practice towards water, sanitation and hygiene (WASH). Hence, WASH services in schools plays vital role in educational performance and decrease the potential for disease transmission.
WASH in schools advanced monitoring system developed by UNICEF for 11 countries including India and figured out for our country that improved and functional water supply in school in 2008 was 72% and increased to 75% in 2013; functional but single sex toilets (Sanitation) were available in 25% schools in 2008 which was increased to 53% in 2013whereas only 42% schools were providing hygiene facilities. [2] Government of India has started many programs for providing safe WASH at school level.
[3] Some programs are especially dedicated for school environment such as School Sanitation and Hygiene Education (SSHE), [4,5] School Water and Sanitation towards Health and Hygiene (SWASTHH),[6,7,8] Janshala Program, Swachh Vidyalaya Abhiyan,etc. [9,10,11] Other programs are running in India at community level and these programs are also covering the WASH in schools such as Total Sanitation campaign, Jal Jeevan Mission, National Rural Drinking Water Program (NRDWP), [12,13,14,15] However, WASH interventions are the integral part of these programs.
Safe drinking water, sanitation and hygiene beyond the household, and particularly in the school setting, are crucial to the health and education of children. Hence WASH in schools (WinS) is implicitly and explicitly involved in the post-2015 Sustainable Development Goals (SDGs). [16] Sustainable Development Goal-6 is availability of water and sanitation for all; the terms "universal" and "for all" in Targets 6.1 and 6.2 emphasize the need for escalating WASH accessibility from household level to non-household settings, such as schools, as we progress from the MDG to the SDG era.
[16] This "universal" coverage of WASH is also applicable for underprivileged sector such as Ashram schools, tribal community and remote rural settings.
Thus, inclusion of water, sanitation and hygiene (WASH) in schools as part of the SDG, necessitates assessing the coverage and utilization in all types of schools; Government, private, funded including Ashram schools.
Poverty is a major contributing factor for educational backwardness of deprived tribal children. Expenditure on schooling is last or no more priority for the tribal community or low socio-economic strata. [17] In rural settings, unsafe drinking water practices, poor sanitation and hygienic practices were observed in same district. [18,19,20,21,22] The scheme of Ashram School Complex for tribal students is under implementation since 1952. These are residential schools providing residency, uniforms, books, notebooks and other educational equipments to its inmates. [23] Risks of transmission of communicable disease because of the communal eating, sleeping, drinking water, sanitation and hygiene arrangements in boarding schools cannot be ignored.
WinS monitoring system by UNICEF mostly covered the Government and private schools; whereas Ashram schools where children from tribal community are taking education in India are mostly ignored from such developed system, though UNICEF school Wash guidelines set the standards for residential schools too. We plan this study to assess the current wash practices in all Ashram schools of Wardha District. On the basis of assessment, we will develop the need based intervention model which will be helpful for adopting WASH practices by the school staff and students.

Study Design and Study Setting
The school based randomized controlled trial will be carried out in Ashram schools of Wardha district (Maharashtra state, India). Population of Wardha district is 12,96,157 (Census 2011) and distributed in eight blocks namely Deoli, Seloo, Arvi, Hinganghat, Ashti, Samudrapur and Karanja. There are total 08 Ashram schools in Wardha district. Table 1 shows the type, location and class strength of ashram school.

Study Participants and Recruitment
The study participants will be all students of fourth, fifth and sixth standard residing in Ashram school boarding and attending school education. As age group of these standards is suitable to read the intervention material, can act as a leader or members of intervention committee. As we also want to inculcate the safe WASH practices among the children before entering in the adolescent age group.

Sample Size and Sampling
All Ashram schools meant for tribal community in a district will be selected in study Total 460 students are enrolled in all eight ashram schools in fourth, fifth and sixth standards. Complete enumeration technique will be for sampling.

Inclusion Criteria
Student of fourth, fifth and sixth standards and residing in ashram school hostel.

Exclusion Criteria
Student who is absent frequently due to mental or emotional disturbances. Students who are attending the school but they are not residing in the hostel.

Randomization and Concealment
50% of schools will be allocated in intervention arm and other 50% in control arm by simple randomization. Chit papers of all eight ashram schools name and two boxes namely intervention and control arm will be prepared. We will put chit paper one by one in a box alternately in intervention and control box; so that four ashram schools will be allocated in intervention and four schools in control arm.

Data Collection Tools
Data collection tools will be prepared by using the WHO standards for WASH in Schools in Low-cost Settings [24]  3) Questionnaire: Interview questionnaire will cover following parametersi) Awareness and practices related to WASH, ii) Diarrheal diseases, respiratory diseases and school absenteeism among school children. iii) Facilitators and barriers related to improved/safe WASH practices 4) Focus group discussion guide will be prepared to assess the facilitators and barriers to maintain the improved WASH practices at Ashram school level.
Contents of the checklist and questionnaire will be modify according to study objectives and the Ashram school scenario (as the UNICEF modules are prepared from reference for the schools other than the Ashram school).

Methods of Data Collection
1) Survey: All Ashram school (ten) premises will be observed for Water supply, collection, storage practices; sanitation practices (condition and use of urinals, sanitary latrines), liquid waste disposal, surrounding condition of school regarding cleanliness, hygiene practices of teachers and students and Food hygiene (cooking, storage and serving utensils) 2) Interview: Interview of teachers and principal will be taken to assess the knowledge, awareness and practices regarding water storage, purification and filtration, hand hygiene, food hygiene, and body hygiene and sanitation. Interview of children for drinking water, sanitation and hygiene practices will be conducted. We will obtain basic information of school and socio-demographic information of students during these interviews.
3) Focus Group Discussion: One FGD will be conducted among the teachers in each school covering both intervention (five) and control arm (five) to know the facilitators and barriers to maintain the improved WASH practices.

4)
Laboratory testing of school water samples: Water sample will be collected from each school source, storage and consumer point; will be tested in public health laboratory and microbiology laboratory of JNMC, (DMIMS), Wardha for drinking quality standards. This will include investigation for physical, chemical and microbiological parameter.

Baseline Data Collection
All schools intervention and control arm and visited for the baseline assessment.

Intervention Design
Most of the modules related to WASH are developed for schools are applicable to Government or private schools and not for Ashram schools meant for tribal children. Hence on the basis of baseline information replicable and scalable model will be developed which will be suitable for Ashram or residential schools to improve awareness, practices and health conditions related to WASH and package will be implemented in four intervention schools only which are selected by simple randomization. It will consists of -  We will provide module and kit to the committee.

Second Part of Intervention
Goal of any program achieved successfully when utilization by beneficiaries (service users) part achieved effectively. Community mobilization and engagement trigger behavior change and service utilization.
Implementation of WASH practices by teachers and students under the supervision of school superintendent/ Principal and Warden at school level for the duration of eight months.
 Class-WASH committee will be trained to perform WASH activity and monitored by school-WASH committee  WASH activity: Class-WASH committee will demonstrate other students in the Ashram School for WASH practices with the help of module and kit related to WASH practices. Later on they will involve the other students for the same activity.
[ex-speech, demonstration, song, etc.] Periodic playing of health educational video in the class or on the school forum.  School committee will monitor and supervise class committee and school superintendent or Principal will monitor and supervise school committee  School committee will prepare and submit the report to Principal by using monitoring and supervision tool [no. of activity conducted, type of activity conducted in a month, students involved other than class committee]  Research team will coordinate the school level activities periodically and will collect the reports.

End Line Data Collection
Data similar to baseline will be collected after intervention for one year except basic information, socio-demographic information of children.
Focus group discussion or interview of teachers and principal of intervention ashram school will be conducted to obtain the opinion of intervention package regarding the benefits and barriers. Table 2 shows the type of activity and duration of study.

Outcome Assessment
Intermediate assessment for study variables will be conducted after four months and end line assessment will be conducted after eight months of implementation of WASH model. Assessment data will be collected from both intervention and control arm schools. Tools and techniques will be used similar to baseline assessment.

Dependent Variables
• Health indicators-diarrheal diseases, respiratory infection, • Changes in awareness and practices related to Water, Sanitation and Hygiene (WASH) among school teachers, staff and children, • School absenteeism • Changes in school environment

Confounders
Funds received by the Ashram school, location (distance from city place) Fig. 2 shows the detail conceptual framework of intervention study design.

Primary outcome
i) Improvement in practices related to Water, Sanitation and Hygiene at school level ii) Decrease in diarrheal diseases and respiratory infection associated with WASH practices among staff and children iii) Decrease in students' absenteeism in school due to diseases

Secondary outcome
i) Improvement in awareness related to Water, Sanitation and Hygiene at school level ii) Improvement in school environment for example cleanliness, waste disposal, etc.

Statistical Analysis
Descriptive statistics were calculated by aggregating individual-level data to the school level where necessary and using two-sample ttests to assess the differences in means between beneficiary and comparison schools. Unadjusted mean percentages for all outcome variables were calculated by aggregating individual-level data to the school level. To quantify the impact of the program, we used intention to-treat analyses utilizing mixed-effects logistic regression models that compared beneficiary schools to the matched comparison schools, without regard to program adherence.

Scope, Implications and limitations
The scope of the study shown in figure 1 in the form of input, output, outcome and overall impact of the research.

Benefit to Ashram Schools
 The intervention package is based on community mobilization and participation through development of school WASH committee.  Life skill education-It will create the example of life skill education as the Class WASH committee will be made up of students. And students will experience the team formation, leadership, team work and participatory approach.  Capacity building or upgrading of school teachers and staff through training in practices related to WASH will contribute to bring long term changes and improvement in health status of school children.  Each School selected for intervention will be receiving a kit related to WASH practices.

Benefits to the Community
 As intervention is mainly for school going, which is age of building the healthy WASH practices and if this interventions improve their WASH practices; it will be carried over later life and will transform the community (tribal).

Benefits to the EMIS (Management Information System)
 One of the components of SDG target is improving WASH in schools; monitoring system covers the government and private schools. During this study innovative data of Ashram schools (residential schools) will be generated and can be shared, if required.  WHO health promoting schools -Study finding can be shared to Global School initiative program

CONCLUSION
The intervention package is based on community mobilization and participation; life skill education, capacity building of school staff related to WASH. This will contribute to bring long term changes and improvement in health status and academic performance of school children. As intervention is mainly for school going, which is age of building the healthy WASH practices and if this interventions improve their WASH practices; it will be carried over later life and will transform the community (tribal). During this study innovative data of Ashram schools will be generated and can be shared to monitoring system, if required.

LIMITATIONS
As the study will be conducted in Ashram schools, results of this trial will be more suitable for other residential schools; as effect of WASH practices among children and parents at household level will be escaped.

CONSENT
Before randomization we will obtain the written consent from school Principal/Head Masters for participation in the study. Informed consent will be taken from teachers to participate in study and share the information.

ETHICS APPROVAL
Institutional Ethics Committee approval is obtained from the ethics committee of the DMIMS University.