The United Nations Millennium Development Goal 2.A is to “ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling” [1
]. Inadequate water and sanitation facilities in the school environment have been reported as a major hindrance towards achievement of this goal. Many schools in developing and developed countries lack adequate water and sanitation services, with associated potential detrimental effects on health and school attendance [2
The goal of this review is to characterize how inadequacies in water and sanitation in the school environment have the potential to or are impacting the health of children and their attendance in schools. We sought to identify all claimed effects of adequate or inadequate water and sanitation access in the school environment by cataloguing peer-reviewed journal articles on the subject, defining the scope of effects, and highlighting possible future research directions within the field. The school environment represents an important setting because many children’s social habits and behaviors are learned at school. School WASH interventions improve overall sanitation, hygiene and daily water intake in both educational and non-educational environments [4
]. According to the World Health Organization, 11% more girls attend school when sanitation is available [5
]. Many children in both developing and developed nations spend time absent from schools due to diseases contracted within the school environment [6
2.1. Criteria for Inclusion
Published peer reviewed literature was screened and reviewed and peer reviewed journal articles that documented an educational or health effect associated with provision or absence of water and/or sanitation in schools selected. These impacts include an increase or decrease in school attendance, school dropouts, or any type of physical, social or psychological illness. The review was restricted to studies that explicitly explored the effects of the provision or absence of water, sanitation, and related hygiene materials such as soap, towels, and toilet paper in the school environment; studies that only examined the effects of behavior changes were excluded. Dissertations were not included. Articles without abstracts or full texts available were not included. Studies concerning day care centers were excluded. Studies on hand sanitizers were excluded.
We categorized ‘water’ interventions as either those for hand washing—including water, wash basins, soap, and drying devices, or for drinking. Studies considering only the impact of fluoride in drinking water were also excluded from the review, as the effects of fluoride on oral health in schools have been widely studied. Sanitation was defined as the availability of facilities to urinate or defecate (private, safe toilets, latrines, and availability of toilet paper) or as facilities for women and girls to manage menstruation (private location, and means for management or disposal of menstrual hygiene materials). Studies on the impact of availability of sanitary napkins were not included. The outcomes targeted by this review included health and educational outcomes. Health effects included in the study encompassed all of the defined social health, mental and physical health topics recognized by the National Institute of Health. Educational outcomes included school attendance and academic performance.
Studies were classified into seven non-exclusive categories: intervention trials, randomized control trials, observational studies, participatory research studies, descriptive studies, cross-sectional studies and outbreak investigations. Studies were also organized by economic status and field topic in order to better organize the results of the search.
2.2. Search Strategy for Identification of Studies
The following major scientific, electronic databases were searched during the months of October through December 2010: PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google. In March 2012 a follow-up scan for subsequently published papers was conducted and five articles that met the inclusion criteria were added to the review.
The primary search was based on the keywords: Schools and Water or Sanitation, Gender and Water or Sanitation, Girls and Water or Sanitation, Menstruation and Water or Sanitation, School Absenteeism and Water or Sanitation, School Health Policies and Water or Sanitation, WASH (Water, Sanitation, and Hygiene) and Schools. All references in the bibliographies of included documents were also systematically searched for relevant documents. The study was restricted to documents for which an abstract and article in English was available.
The search included no time or location restrictions. Studies not written in English, or without an English translation available, were not included in this review. A secondary reviewer completed the review independently. Consensus was reached between primary and secondary reviewers in all cases of initial disagreement.
The school environment is an important sector to explore due to the social and health influences schools have on children [4
]. In addition, the school environment is important for interventions aimed at mitigating infectious diseases spread because children may be introduced to more, and more strains of pathogens in the school, due to the fact that more children are present, in contact with, and using the facilities [6
]. This exposure makes the school environment efficacious for performing infectious diseases interventions based on water, hygiene, and sanitation [6
In comparing the efficacy of interventions conducted in developing and developed settings, and between regions within these categories, differences in results may be partly explained by varying baseline rates of disease. In similar studies on provision of water for handwashing, Rosen et al.
, in Israel found no significant changes in rates of illness or absenteeism, while similar studies in China and Egypt noted significant changes in rates of illness [30
]. A feasible explanation for differences in these findings is the variation in prevalence of target illnesses between particular regions at the start of the intervention. Differences in the effect of an intervention in varying areas may be due to confounders that are best controlled for using blinding and randomized control trials. The future use of more high quality epidemiological studies such as this will control for confounders and elucidate the effects of water and sanitation in schools across diverse regions and nations.
The scope of our review with respect to water and sanitation facilities related to management of menstruation in schools was limited. Our criteria excluded papers related to the availability of sanitary napkins in schools. Though there is a large body of evidence within this field, and the outcomes related to it are critical in understanding the role of menstruation on school performance and absenteeism, it was outside the scope of this review. The available evidence supports the claim that a lack of water and sanitation facilities to manage menstruation in schools leads to discomfort and avoidance of school during menstruation. Freeman et al.
, have shown a decrease in absenteeism among girls after water and hygiene interventions [4
]. This is particularly significant in light of high drop-out rates among young women in many developing countries [54
]. The relationship between education and women’s health, economic success and educational status has been documented [55
]. Measures that enable women and girls to continue attendance in educational environments are essential to achieving the Millennium Development Goals of universal education and promoting women’s gender equality and empowerment.
This review revealed areas for future research. Future studies should examine the relationship between drinking water and sanitation provision in schools. It has been suggested in the literature that a link may exist between unwillingness to drink water at school in order to avoid using unsanitary school toilets [50
]. This interaction could lead to insufficient hydration and corresponding health effects [50
]. In addition, chemical contaminants such as lead have the potential to impact children’s development, yet little research exists on their prevalence in schools. This is particularly important in resource-poor settings, considering that all studies on this topic were conducted in the United States. In addition, it is unclear whether interventions in the school have the potential to impact the hygiene behaviors of caregivers at home. Blanton et al
., found a significant increase in household water treatment practices that was sustained over one year after their intervention in Kenya [17
]. However in their study, Freeman and Clasen found no significant differences in household uptake of water treatment practices one year after their school intervention in India [27
]. High quality studies of programs targeted at water and sanitation access in schools that monitor the costs, benefits, sustainability and long-term impact on student and caregiver behavior are areas that could be further explored to usefully supplement this body of literature.
Potential errors in study identification and inclusion were mitigated by including a secondary reviewer. As studies were limited in number, used diverse methods and metrics and were conducted in various countries, findings may not be generalizable. No attempt was made to weight the value of the findings of studies according to study quality.
The World Health Organization has issued guidelines for water, sanitation, and hygiene implementation in schools in low cost settings [56
]. Implementation of these regulations at the national level could result in improved water and sanitation conditions in schools. Such regulations would serve to overcome barriers to education, particularly in low resource settings where schools, teachers, and administrators may not recognize the potential impact of water and sanitation on health and education.
This review identified the health and educational effects of water and sanitation in schools. The goal of the review was to catalogue and characterize existing studies in the field. The review concluded that studies document higher rates of infectious, gastrointestinal, neuro-cognitive and psychological illnesses where school children were exposed to inadequate water and sanitation facilities. Potential areas for future research were identified. The evidence of widespread inadequate facilities suggests that greater resources and attention need to be invested in this field by school management, bureaucrats and multilateral and civil society organizations.
The overall reasoning behind attention to water and sanitation in schools is logical. Respiratory and gastrointestinal diseases are one of the leading causes of death for children globally [57
]. The evidence summarized in this paper supports there being a link between gastrointestinal and other diseases has important implications for children’s health worldwide. In order to achieve universal access to education as a right for all children, the underlying factors of water and sanitation provision in the school environment and their impacts on health and educational outcomes must be addressed through more rigorous investigation, political attention, and effective intervention.