An evaluation of water, sanitation and hygiene interventions towards effective response to infectious diseases : a case study of schools in Uasin Gishu, Kenya

Abstract

Background Access to safe water, sanitation, and hygiene (WASH) is essential for improving health and educational outcomes, particularly in low- and middle-income countries (LMICs). In Kenya, school WASH implementation remains uneven, with persistent gaps in infrastructure, hygiene practices, and policy implementation. The COVID-19 pandemic exposed these weaknesses and highlighted the need for sustainable WASH interventions to strengthen infection prevention and pandemic preparedness in schools. This study aimed to develop and validate an appropriate WASH intervention for primary schools in Uasin Gishu County, Kenya. Methods A multi-phase mixed-methods case study design was employed. Phase 1A involved a systematic review of WASH interventions in primary schools in LMICs, resulting in 69 eligible studies. Phase 1B comprised a mixed-methods case study in 51 proportionally sampled primary schools (24 rural and 27 urban) selected from 498 schools in the county. Quantitative data were collected using questionnaires and observation checklists, while qualitative data were obtained through focus group discussions with teachers. Phase 2 utilized a two-round Delphi consensus technique involving 20 purposively selected WASH experts to identify, refine, and prioritize key intervention components. Phase 3 consisted of a stakeholder validation workshop with 15 experts from the education, health, water, and school management sectors to assess the feasibility, relevance, and acceptability of the proposed intervention. Results The systematic review demonstrated that effective school WASH programs are characterized by integrated approaches combining infrastructure improvement, behavior change, and governance support. Promising interventions included hand hygiene promotion, health education, peer-led approaches, menstrual hygiene management, and group handwashing facilities. The school case study revealed important gaps in WASH provision. While 61% of schools had access to piped water and 67% reported water availability for handwashing throughout the day, 59% lacked soap at handwashing stations and 73% lacked disability-friendly water access infrastructure. Although 75% of schools provided menstrual products, only 22% had changing rooms and 25% had sanitary disposal facilities. In addition, 67% of schools lacked a school WASH policy. Key deficiencies were identified in menstrual health management, disability-inclusive infrastructure, water quality monitoring, and policy implementation. Delphi findings showed strong expert consensus (74–100% agreement) on the need for dedicated WASH budgets, clear governance structures, inclusive infrastructure, menstrual hygiene management, curriculum integration, monitoring systems, capacity building, and multisectoral collaboration. These findings informed the development of a three-pronged intervention comprising a learner-centred menstrual health guide, a WASH Pyramid Framework, and a policy brief. Stakeholder validation confirmed the relevance, feasibility, and sustainability of these interventions, while identifying inadequate funding, policy gaps, cultural barriers, and sustainability concerns as potential implementation challenges. ii Conclusion This study provides comprehensive evidence on WASH conditions in primary schools and highlights critical inequities in infrastructure, service delivery, and governance in Uasin Gishu County, Kenya. Through a rigorous multi-phase process, it developed and validated a context-specific three-pronged WASH intervention consisting of a menstrual health guide, a WASH Pyramid Framework, and a policy brief. The findings demonstrate that integrated WASH approaches combining infrastructure, behavior change, governance, and policy support are essential for strengthening infection prevention, enhancing school resilience, and improving preparedness for future public health emergencies.