Water, sanitation, and hygiene in primary schools: Determining health and educational impacts and developing a model for sustained service delivery in Kenya

Less than half of primary schools in low- and middle-income countries have access to safe drinking water and appropriate sanitation. Fewer still provide students with the hardware or education needed to enable effective handwashing with soap. Improving school water, sanitation, and hygiene (WASH) is associated with reduced absence and improved health among school-aged children. School-based interventions provide a pathway to improving health in the broader community. However, programs suffer from poor service delivery and sustainability beyond intervention periods. Though a series of analyses, this dissertation examines the potential health and educational impacts of school WASH improvements and the determinants of sustained WASH service delivery in public primary schools.;Using data from a cluster-randomized trial, we examine the impact of multiple school WASH interventions on health outcomes among children under the age of five with a sibling attending an enrolled school. Sanitation and water treatment were not associated with health gains. However, school water supply interventions were associated with statistically significant declines in diarrheal episodes among children under the age of five and fewer clinic visits for diarrhea and/or vomiting.;Baseline data from the same trial were used for a detailed examination of short-term educational outcomes (i.e. absence in the past two weeks). The same social and demographic patterns associated with school enrollment are associated with absence, particularly: gender, age, and household wealth. WASH characteristics at the home have a stronger association with the probability of absence in the past two weeks than any single school WASH characteristic. Findings suggest that quality of WASH facilities at school has a stronger association with absence than the quantity of facilities.;For WASH services to achieve health and educational impacts, services must be made available to students and sustained over time. We present data from an iterative series of quality studies and trials of improved practices to examine local stakeholder (pupils, teachers, school officials, and district officials) experiences with and perceptions of school WASH service provision. We provide concrete recommendations and intervention strategies at the school, community, and policy levels for improving delivery of school WASH services.