Evaluation of the Dubai Cares WASH in School Initiative
Condition: Absenteeism; Diarrhea; Respiratory Tract Infections
MeSH terms: Respiratory Tract Infections; Diarrhea
Study type: Observational

Summary: 
      This study will use longitudinal data collection to quantify the impact of a school-based
      water, sanitation and hygiene (WASH) program in Mali, West Africa, on pupil absenteeism,
      diarrheal illness, and respiratory illness.

      Data will be collected from 100 intervention and 100 control schools across 4 regions in
      Mali. At each school research staff will randomly select 60 pupils in grades 3-6 (typically
      ages 7-14). Research staff will ask school directors to provide written consent for pupil
      participation in place of parents, a procedure that has been approved by the Malian Ministry
      of Education. Research staff will approach selected pupils at school to request informed oral
      assent for participation. The informed assent process and data collection will be conducted
      by local trained enumerators in the child's preferred language of French or Bambara. Oral
      rather than written assent was chosen due to varied literacy capabilities and to limit
      paperwork that identifies participants.

      Data collection will take place at each school once every six to eight weeks during the
      duration of two school years. Research staff will conduct observations of school facilities,
      observations of handwashing behavior of children upon leaving latrines, and an interview with
      the school director about WASH conditions and school enrollment information. None of these
      school activities collect personal data or identifiers. Data collection with pupils will be
      done with the same pupils every 6-8 weeks and entails a 5-minute interview asking about
      recent absence and symptoms of diarrhea and respiratory illness.

      All data collection will occur at the school, will be conducted by trained local enumerators,
      and will be stored on password-protected mobile data collection devices. Data will be
      uploaded to a password-protected server and will not contain personal identifying
      information. Enumerators will maintain a separate form that links pupil IDs with names, which
      will be kept confidential. There are no direct benefits other than contribution to general
      knowledge that will inform future school WASH projects. There are no risks to participation
      other than a small amount of class time missed by pupils, and great efforts will be made to
      minimize time outside of class.
    

Detailed description: 
      BACKGROUND AND SPECIFIC AIMS

      Household-based water, sanitation and hygiene (WASH) improvements have demonstrated
      reductions in diarrheal. However, there is little academically sound research on the impact
      of school-based programs. The small body of current evidence is promising; school-based WASH
      interventions have been associated with reductions in absenteeism, particularly among girls.
      School WASH programs have also demonstrated decreases in diarrheal disease and helminth
      reinfection rates among school children.

      In 2010, a consortium between UNICEF, CARE Mali, Oxfam GB, WaterAid Mali and Save the
      Children was launched to implement WASH programming in over 700 primary schools across Mali
      under the Dubai Cares WASH in Schools Initiative (DC Mali Initiative). Core activities of the
      project include: installing or rehabilitating school water points, latrines and hygiene kits;
      promoting good WASH practices and behavior change at school and within the community; and
      establishing management systems to ensure sustained financing, monitoring and maintenance.

      The specific aim of this study is to quantify the impact of the DC Mali Initiative on pupil
      learning and health. Using longitudinal data collection, investigators will assess
      absenteeism, diarrhea, and respiratory infections in 100 intervention schools and compare the
      results to those observed in 100 control schools.

      DATA COLLECTION ACTIVITIES

      Facility Observations will be conducted by trained study enumerators using electronic data
      collection devices. The observations will be of the school facilities specifically, not of
      the students.

      Structured Director Interviews will be administered to the school director. In the case where
      the school director is not available, an adjunct director with knowledge of school WASH
      facilities will be interviewed. Responses will be recorded on electronic data collection
      devices by trained enumerators. The questionnaire will address presence and functionality of
      school WASH facilities, and should take no more than 20 minutes. The information collected in
      this interview is a report on the state of facilities at the school and is not sensitive
      personal information.

      Structured Pupil Interviews will be administered to a random sample of 40 pupils at each
      school. Pupils in grades 3-6 (typically ages 7-14) will be eligible for the sample. As this
      is a longitudinal study, the same pupils will be interviewed during each visit. New pupils
      will be selected at the start of the second academic year in September 2013 to replace those
      pupils who graduated or dropped out during the 2012-2013 academic year. Upon initial
      recruitment and after obtaining informed oral assent, pupil names will be recorded on a
      master list of participants, which will assign an ID to each participant. This list will be
      kept confidential by each enumerator. Enumerators will only record the corresponding ID
      number on data collection forms, and no names will be permanently recorded in the database.
      Pupil interview responses will be recorded on electronic data devices by trained enumerators.
      The interview will address recent history of school absenteeism, diarrheal illness, and
      respiratory illness. Pupils will also provide information about their age, grade, presence of
      a latrine at home, and academic grade the previous year. The pupil interview will take no
      more than five minutes per pupil. Interviews will be conducted in either French or the local
      language, according to the preference of the pupil.

      A Roll Call will be taken of all pupils in the school on the day of each visit. Upon the
      first visit, enumerators will record a list of all pupils enrolled in the school. These lists
      with data will be kept confidential by enumerators and will not be shown to school
      administrators or others not involved in the research. At each data collection visit,
      enumerators will call the name of each pupil in the class and mark whether the pupil is
      absent. This method will be used to triangulate attendance data with school roster records.
      Aggregate data from all visits will be recorded in the database without any personal
      identifying information.

      Handwashing observations will be made of pupils upon exiting latrines. Enumerators will
      observe the latrine area for 20 minutes and tally whether or not pupils use water and/or soap
      after leaving the latrine. No names or other personal or identifying information will be
      collected.

      An Academic Data Review will be conducted three times throughout the 2012-13 and 2013-14
      school years to determine percentage of children obtaining a passing average, percentage of
      children advancing to the next class, and percentage of drop-outs at each school. Only
      school-level data, disaggregated by gender and grade, will be collected during this review.
      No individual or personal data will be collected for this activity.

      DATA MANAGEMENT AND MONITORING

      This trial does not entail a medical intervention of any kind; therefore, a typical data
      safety and monitoring plan is not necessary. Study staff will be instructed to monitor any
      unforeseen situations that suggest an increase in risk to participants and immediately inform
      the study manager so that a decision can be made on how to mitigate those risks.

      RISKS AND BENEFITS OF PARTICIPATION

      Participation in the study will not subject participants to any excess risk other than a
      brief five-minute interruption of class time during classroom roll call, and a five-minute
      break from class for pupil participants to leave class for their interviews.

      There are no direct benefits to participants other than knowing that information gained from
      this study will contribute to knowledge in the WASH sector worldwide about the educational
      and health impacts of improved WASH in schools. Schools participating as controls will be
      placed in high consideration by DC Mali Initiative partners for future interventions.

      CONFIDENTIALITY

      Names of pupil participants will be recorded separately from survey forms and will be
      destroyed after data collection has been completed. This information will only be retained on
      a separate ID linking form to ensure the same pupils are contacted in repeat visits to the
      school. Private health data relating recent history of diarrhea and respiratory illness will
      be linked to demographic information including age, gender, school, and school grade;
      however, this information will be insufficient to serve as an identifier. No identifiers will
      leave Mali

      INFORMED CONSENT

      The Malian Ministry of Education has granted a waiver of parental consent for pupil
      interviews. At each school, school directors will be asked to sign in loco parentis ("in the
      place of parent") on behalf of the pupil participants. These forms inform the director of the
      activities and purpose of the research and give permission to the researchers to carry out
      short interviews at the school with consenting pupils.

      In addition to the loco parentis form, all pupil subjects selected to respond to the pupil
      interview will be read a full informed oral assent script the first time the interview is
      conducted. They will provide oral assent if they choose to participate in the longitudinal
      study. Continued assent will be obtained from pupils before commencing all subsequent data
      collection rounds. Oral assent rather than written has been chosen due to varying levels of
      literacy at the school as well as a desire to minimize paperwork that contains participants'
      names.

      Investigators expect to sample 60 pupils per school. Therefore, school directors would sign
      the in loco parentis form for up to 60 pupils at each school. This form will be signed at the
      first visit, and will serve as consent for all subsequent visits. A total of 200 in loco
      parentis forms will be collected from school directors. A maximum of 12,000 oral assents will
      be recorded from the pupils during the first round of data collection, with an equal number
      of assents during each of the following data collection rounds.
    

Intervention name(s): Dubai Cares beneficiary
Intervention type(s): Other
Intervention description(s): Installation or rehabilitation of school water points, latrines and hygiene kits; promotion of good WASH practices and behavior change at school and within the community; establishment of management systems to ensure sustained WASH financing, monitoring and maintenance.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Primary school students attending public schools in the Koulikoro, Sikasso, Bamako, and
        Mopti regions of Mali
      
Keywords: WASH; schoolchildren; absenteeism