***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background : We conducted a cluster-r and omized water , sanitation , and hygiene trial in 185 schools in Nyanza province , Kenya . The trial , however , had imperfect school-level adherence at many schools . The primary goal of this study was to estimate the causal effects of school-level adherence to interventions on pupil diarrhea and soil-transmitted helminth infection . Methods : Schools were divided into water availability groups , which were then r and omized separately into either water , sanitation , and hygiene intervention arms or a control arm . School-level adherence to the intervention was defined by the number of intervention components — water , latrines , soap — that had been adequately implemented . The outcomes of interest were pupil diarrhea and soil-transmitted helminth infection . We used a weighted generalized structural nested model to calculate prevalence ratio . Results : In the water-scarce group , there was evidence of a reduced prevalence of diarrhea among pupils attending schools that adhered to two or to three intervention components ( prevalence ratio = 0.28 , 95 % confidence interval : 0.10 , 0.75 ) , compared with what the prevalence would have been had the same schools instead adhered to zero components or one . In the water-available group , there was no evidence of reduced diarrhea with better adherence . For the soil-transmitted helminth infection and intensity outcomes , we often observed point estimates in the preventive direction with increasing intervention adherence , but primarily among girls , and the confidence intervals were often very wide . Conclusions : Our instrumental variable point estimates sometimes suggested protective effects with increased water , sanitation , and hygiene intervention adherence , although many of the estimates were imprecise The impact of improved water , sanitation , and hygiene ( WASH ) access on mitigating illness is well documented , although impact of school-based WASH on school-aged children has not been rigorously explored . We conducted a cluster-r and omized trial in Nyanza Province , Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary -school pupils . Two study population s were used : schools with a nearby dry season water source and those without . Pupils attending ' water-available ' schools that received hygiene promotion and water treatment ( HP&WT ) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools . Those pupils in schools that received only the HP&WT showed similar results . Pupils in ' water-scarce ' schools that received a water-supply improvement , HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness . Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea Background Increased education of girls in developing context s is associated with a number of important positive health , social , and economic outcomes for a community . The event of menarche tends to coincide with girls ' transitions from primary to secondary education and may constitute a barrier for continued school attendance and performance . Following the MRC Framework for Complex Interventions , a pilot controlled study was conducted in Ghana to assess the role of sanitary pads in girls ' education . Methods A sample of 120 schoolgirls between the ages of 12 and 18 from four villages in Ghana participated in a non-r and omized trial of sanitary pad provision with education . The trial had three levels of treatment : provision of pads with puberty education ; puberty education alone ; or control ( no pads or education ) . The primary outcome was school attendance . Results After 3 months , providing pads with education  significantly improved attendance among participants , ( lambda 0.824 , F = 3.760 , p<.001 ) . After 5 months , puberty education alone improved attendance to a similar level ( M = 91.26 , SD = 7.82 ) as sites where pads were provided with puberty education ( Rural M = 89.74 , SD = 9.34 ; Periurban M = 90.54 , SD = 17.37 ) , all of which were higher than control ( M = 84.48 , SD = 12.39 ) . The total improvement through pads with education intervention after 5 months was a 9 % increase in attendance . After 3 months , providing pads with education  significantly improved attendance among participants . The changes in attendance at the end of the trial , after 5 months , were found to be significant by site over time . With puberty education alone result ing in a similar attendance level . Conclusion This pilot study demonstrated promising results of a low-cost , rapid-return intervention for girls ' education in a developing context . Given the considerable development needs of poorer countries and the potential of young women there , these results suggest that a large-scale cluster r and omized trial is warranted . Trial Registration Pan African Clinical Trials Registry Background Inadequate nutrition ; neglected topical diseases ; and insufficient water , sanitation , and hygiene ( WASH ) are interrelated problems in schools in low-income countries , but are not routinely tackled together . A recent three-year longitudinal study investigated integrated school health and nutrition approaches in 30 government primary schools in southern Ethiopia . Here , we report on baseline associations between sanitation , hookworm infection , anemia , stunting , and wasting . Methods In each school , the Schistosoma mansoni , S. haematobium , and soil-transmitted helminth infection intensities ; blood hemoglobin concentrations ; heights ; and weights of approximately 125 students were assessed . Of these 125 students , approximately 20 were r and omly selected for student WASH surveys . Of these 20 , approximately 15 were r and omly selected for household sanitation observations .  School WASH was also assessed through a combination of observations and questions to the headteacher . Mixed-effects logistic regression was used to compare household sanitation with hookworm infection ( the other parasites being much less prevalent ) ; and hookworm infection with anemia , stunting , and wasting . Findings Blood , stool , and urine sample s were provided by 3,729 children , and student WASH and household WASH surveys were conducted with 596 and 448 of these students , respectively . Hookworm , Ascaris lumbricoides , Trichuris trichiura , and S. mansoni infections had prevalences of 18 % , 4.8 % , 0.6 % , and 0.3 % , respectively , and no S. haematobium infections were found . Anemia , stunting , and wasting had prevalences of 23 % , 28 % , and 14 % , respectively . No statistically significant associations were found between latrine absence or evidence of open defecation at home , and hookworm infection ( adjusted odds ratio , OR = 1.28 , 95 % confidence interval , CI : 0.476–3.44 ; and adjusted OR = 1.21 , 95 % CI : 0.468–3.12 ; respectively ) ; or between hookworm infection and anemia , stunting , or wasting ( adjusted OR = 1.24 , 95 % CI : 0.988–1.57 ; adjusted OR = 0.992 , 95 % CI : 0.789–1.25 ; and adjusted OR = 0.969 , 95 % CI : 0.722–1.30 ; respectively ) . Conclusions In this setting , no statistically significant associations were found between sanitation and hookworm ; or between hookworm and anemia , stunting , or wasting . More evidence on best practice s for integrated school health interventions will be gathered from the follow-up surveys in this study OBJECTIVES Improving school water , sanitation and hygiene ( WASH ) conditions reduces pupil absence and illness . However , these benefits may depend on the conditions of the latrines and availability of consumables . We sought to determine whether a low-cost , policy-relevant , environmental-level latrine cleaning intervention could improve latrine cleanliness , increase its use and reduce absenteeism . METHODS In a three-arm , cluster-r and omized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project .  Latrine conditions and use were also assessed using structured observation . Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls , as did h and washing with soap . We found no difference in latrine use and absence across arms . CONCLUSIONS The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received . Improving latrine conditions is important for the dignity and well-being of pupils , and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly Evidence of the impact of water , sanitation , and hygiene ( WASH ) in schools ( WinS ) interventions on pupil absence and health is mixed . Few WinS evaluations rigorously report on output and outcome measures that allow for comparisons of effectiveness between interventions to be made , or for an underst and ing of why programs succeed . The Water , Sanitation , and Hygiene for Health and Education in Laotian Primary Schools ( WASH HELPS ) study was a r and omized controlled trial design ed to measure the impact of the United Nations Children ’s Fund ( UNICEF ) Laos WinS project on child health and education . We also measured the sustainability of intervention outputs and outcomes , and analyzed the effectiveness of group hygiene activities on behavior change and habit formation . Here , we present the design and intermediate results from this study . We found the WinS project improved the WASH environment in intervention schools ; 87.8 % of schools received the intervention per design . School-level adherence to outputs was lower ; on average , schools met 61.4 % of adherence-related criteria . The WinS project produced positive changes in pupils ’ school WASH behaviors , specifically increasing toilet use and daily group h and washing . Daily group hygiene activities are effective strategies to improve school WASH behaviors , but a complementary strategy needs to be concurrently promoted for effective and sustained individual h and washing practice at critical times Background Evidence from recent studies assessing the impact of school water , sanitation and hygiene ( WASH ) interventions on child health has been mixed . Self-reports of disease are subject to bias , and few WASH impact evaluations employ objective health measures to assess reductions in disease and exposure to pathogens . We utilized antibody responses from dried blood spots ( DBS ) to measure the impact of a school WASH intervention on infectious disease among pupils in Mali . Methodology /Principal findings We r and omly selected 21 beneficiary primary schools and their 21 matched comparison schools participating in a matched-control trial of a comprehensive school-based WASH intervention in Mali .  DBS were collected from 20 r and omly selected pupils in each school ( n = 807 ) . We analyzed eluted IgG from the DBS using a Luminex multiplex bead assay to 28 antigens from 17 different pathogens . Factor analysis identified three distinct latent variables representing vector-transmitted disease ( driven primarily by dengue ) , food/water-transmitted enteric disease ( driven primarily by Escherichia coli and Vibrio cholerae ) , and person-to-person transmitted enteric disease ( driven primarily by norovirus ) . Data were analyzed using a linear latent variable model . Antibody evidence of food/water-transmitted enteric disease ( change in latent variable mean ( β ) = -0.24 ; 95 % CI : -0.53 , -0.13 ) and person-to-person transmitted enteric disease ( β = -0.17 ; 95 % CI : -0.42 , -0.04 ) was lower among pupils attending beneficiary schools . There was no difference in antibody evidence of vector-transmitted disease ( β = 0.11 ; 95 % CI : -0.05 , 0.33 ) . Conclusions / Significance Evidence of enteric disease was lower among pupils attending schools benefitting from school WASH improvements than students attending comparison schools . These findings support results from the parent study , which also found reduced incidence of self-reported diarrhea among pupils of beneficiary schools . DBS collection was feasible in this re source -poor field setting and provided objective evidence of disease at a low cost per antigen analyzed , making it an effective measurement tool for the WASH field . Trial registration The trial was registered at Clinical Trials.gov ( NCT01787058 OBJECTIVE To determine the impact of environmental nudges on h and washing behaviours among primary school children as compared to a high-intensity hygiene education intervention . METHODS In a cluster-r and omised trial ( CRT ) , we compared the rates of  h and washing with soap ( HWWS ) after a toileting event among primary school students in rural Bangladesh . Eligible schools ( government run , on-site sanitation and water , no hygiene interventions in last year , fewer than 450 students ) were identified , and 20 schools were r and omly selected and allocated without blinding to one of four interventions , five schools per group : simultaneous h and washing infrastructure and nudge construction , sequential infrastructure then nudge construction , simultaneous infrastructure and high-intensity hygiene education ( HE ) and sequential h and washing infrastructure and HE . The primary outcome , incidence of HWWS after a toileting event , was compared between the intervention groups at different data collection points with robust-Poisson regression analysis with generalised estimating equations , adjusting for school-level clustering of outcomes . RESULTS The nudge intervention and the HE intervention were found to be equally effective at sustained impact over 5 months post-intervention ( adjusted IRR 0.81 , 95 % CI 0.61 - 1.09 ) . When comparing intervention delivery timing , the simultaneous delivery of the HE intervention significantly 
    Output:
    
The papers were analysed in groups , based on four categories of reported outcomes : ( i ) reduction of diarrhoeal disease and other hygiene-related diseases in school students ; ( ii ) improved WASH knowledge , attitudes and hygiene behaviours among students ; ( iii ) reduced disease burden and improved hygiene behaviours in students ’ households and communities ; ( iv ) improved student enrolment and attendance .
Several studies provide evidence of positive disease-related outcomes among students , yet other assessment s did not find statistically significant differences in health or indicated that outcomes are dependent on the nature and context of interventions .
Evidence of the impact of school-based WASH programs in reducing student absence from school was mixed .
Ensuring access to safe and sufficient water and sanitation and hygiene promotion in schools has great potential to improve health and education and to contribute to inclusion and equity , yet delivering school-based WASH intervention does not guarantee good outcomes .