The individual and combined impacts of school-based water, sanitation, and hygiene (WASH) education and infrastructure operation and maintenance (O&M): A factorial cluster-randomized controlled trial in Uttar Pradesh, India

IntroductionWhile improving water, sanitation, and hygiene (WASH) service delivery in schools supports the Sustainable Development Goals, rigorous trials have recently reported inconsistent effects of WASH in schools (WinS) programmes on student behaviour and health. We examined the individual and combined impacts of WASH education and infrastructure operation and maintenance (O&M) interventions on student knowledge, facility conditions, and hygiene behavior. MethodsThis four-arm cluster-randomized controlled trial (cRCT) was conducted over one year in 200 public primary schools of Uttar Pradesh, India. Pre-baseline infrastructure repairs were made to normalize access to WASH facilities in all schools. Interventions included a teacher-delivered, play-based WASH curriculum and a third-party O&M service including a part-time cleaner. Schools were randomized to Curriculum, O&M, Curriculum + O&M, or Control arms. We measured study outcomes with student and teacher surveys at three time points, and through unannounced behavior and infrastructure observations at nine and eight time points, respectively. ResultsThe Curriculum intervention significantly improved all measured student WASH knowledge outcomes, whereas O&M alone showed no effect. Students in the Curriculum + O&M arm had the strongest gains, with 9.7 times greater odds of accurate germ knowledge (aOR: 9.67; p<0.001). The O&M intervention yielded significant and sustained improvements in toilet-related infrastructure outcomes, making toilets more likely to be unlocked, clean, functional, and to have water available for anal cleansing. Neither intervention, individually or combined, significantly changed observed rates of student toilet use or handwashing. ConclusionThe curricular intervention was effective at improving students WASH-related knowledge, and the O&M intervention was effective at improving the quality of WASH service provision. These interventions, either alone or in combination, were insufficient to produce significant changes in student hygiene behavior. Future WinS research should consider the potential of normative behavior change theories. KEY MESSAGES What is already known on this topic[bullet] School-based interventions have produced mixed results on student behavior change, health, and absenteeism. [bullet]Few prior studies have assessed the impact of improved O&M of school WASH facilities on service provision, student behavior, or health. What this study adds[bullet] We found that student knowledge and toilet accessibility, functionality, and cleanliness improved; however, our study was novel in finding that neither WASH education nor WASH infrastructure O&M, alone or in combination, were sufficient to increase student handwashing and toilet use. [bullet]These null results for student behavior change outcomes may help explain the numerous WinS studies that have found mixed or negligible changes in diarrhea, respiratory infection, and absenteeism. How this study might affect research, practice or policy[bullet] Our results suggest that the researcher and practitioner community has not yet discovered how to reliably drive significant and scalable change in student WASH behaviors. Future research should aim to understand the mechanisms by which student behaviors change in the school environment to produce consistent and scalable benefits, including the role of norms.