IRC materials used in systematic review of evidence of impact of separate toilets for girls

Published on: 16/01/2012

IRC materials and web sites on WASH in Schools were used in an academic study of the London School of Hygiene & Tropical Medicine and Institute of Education. What impact does the provision of separate toilets for girls at school have on their primary and secondary school enrolment, attendance and completion? A systematic review of the evidence is the title of a collaborative project of the London School of Hygiene & Tropical Medicine and Institute of Education, with guidance by Save the Children USA, UNICEF & Care International.

Birdthistle I, Dickson K, Freeman M & L Javidi. What is the impact of separate toilets for girls at schools on girls’ educational outcomes? A systematic review of the evidence. MARCH Centre at LSHTM and EPPI-Centre, University of London. March 2011.

The authors looked at peer-reviewed journal articles, books / book chapters, published reports and conference papers (e.g. reports from WHO, IRC, or papers presented at conferences, e.g. newsletters).

 They searched 12 websites for relevant research of which three are from IRC:

• OECD
• DFID
• World Bank
• WaterAid
• IRC International Water and Sanitation Centre
• WHO
• CDC
• Health Management Information Consortium (HMIC) database
• WASH Research News (http://washresearch.wordpress.com)  (IRC)
• WASH in Schools (http://www.schools.info)  (IRC)
• freshschools.org
• schoolsandhealth.org

Out of 4,245 citations selected from 11 electronic databases the author screened 78 studies full text scanning reported in 82 papers.

Impact of separate toilets on girls’ educational outcomes could not be assessed

The primary aim of this systematic review was to identify and synthesize evidence of the impact of separate toilets for girls on their enrolment and attendance in schools. The authors did not identify any studies that were designed to assess the impact of separate-sex toilets. And while they identified some evaluations of school-based WASH programmes that included separate toilets for girls, the impact of separate toilets on girls’ educational outcomes could not be assessed for the following reasons:

• All schools in the study had separate-sex toilets, thus precluding a comparison with other arrangements, such as shared toilets or no toilets.
• All schools in the study had shared toilets.
• The educational outcomes were not disaggregated by sex.
• As part of a broader, complex WASH intervention, the relative effects of single components, such as the separate-sex toilets, could not be distinguished.

UNICEF-IRC 6-country study of 2006 one of five reviewed

The UNICEF, IRC (2006) School Sanitation and Hygiene Education Results from the assessment of a 6-country pilot project was one of the five studies identified for their systematic search,  in which separate toilets for girls were included as part of a broader WASH intervention. In each case, the study was supported by UNICEF and designed to evaluate local adaptations of UNICEF’s School Sanitation & Hygiene Education (SSHE), an initiative combining ‘hardware’ (construction of water, handwashing and sanitation facilities) and ‘software’ (training, supervision, joint planning, parent mobilisation, life skills education, children’s clubs, outreach activities) inputs. SSHE promotes a gender-sensitive approach including equal input and responsibilities of boys and girls, and gender-specific facilities including separate toilets for girls and boys.

The five SSHE evaluations show that while UNICEF’s SSHE initiative includes separate toilets for girls, evaluations of SSHE to date have not been designed, and are not capable of, assessing the specific impact of separate-sex toilets on girls’ educational or health outcomes. Reasons for this limitation are discussed below, for each of the five studies:

1. A study was conducted to evaluate the impact and sustainability of SSHE in Kerala, India in 2006, by comparing 150 schools that had completed the intervention four years prior (in 2002), to 150 control schools that had not received the SSHE intervention (Mathew 2009).
2. A pilot study assessed SSHE in 6 countries, by comparing schools before and two years after the intervention, and by comparing intervention schools with control schools in each country (UNICEF/IRC 2006). The number of intervention schools ranged from 10 in Colombia to 64 in Nepal; and the number of control schools ranged from 3 in Colombia to 19 in Zambia.

Both studies collected attendance data, and compared attendance between schools that had received the SSHE intervention and control schools (neither study randomly allocated intervention and control schools). Unfortunately, it is not possible from these two studies to assess the impact of separate sex toilets on school attendance since neither study specified whether the control schools had separate toilets for girls. In both studies, some of the control schools had received interventions sponsored by other agencies/donors, which may have included separate-sex toilets. And in the Kerala study, separate toilets are described as the ‘standard design’, suggesting they would be present in the non-intervention schools. In either case, given the many components of the SSHE intervention, it would be difficult to disentangle the effect of separate toilets from other elements. The authors acknowledge they could not single out the impact of specific components.

Why existing studies cannot answer the key review questions

After contacting authors of 10 studies for separate sex-data the writers concluded that, existing studies cannot answer the key review questions for the following reasons:

1. All schools in the study had separate-sex toilets, thereby precluding a comparison with other arrangements, such as shared toilets or no toilets (e.g., Njuguna 2009, Bowen 2007)
2. All schools in the study had shared toilets (e.g., Koopman 1978)
3. The outcomes were not disaggregated by sex (e.g., Blanton 2010, O’Reilly 2007)
4. Separate-sex toilets are included as part of a comprehensive package of WASH interventions, and the study was not designed to disentangle the effects of single components (e.g., UNICEF/IRC 2006, Mathew 2009). We did not identify evaluations in which the only intervention offered was separate toilets for girls, or where this was phased in before or after other interventions. Rather, separate toilets were one component within a ‘bundle’ of WASH interventions (including ‘hardware’ like the provision of safe water, soap and adequate lighting, as well as ‘software’ such as hygiene education and/or teacher training). Even ‘girl-friendly latrines’ – a concept growing in popularity among international organisations, governments and women’s rights movements – should not only be separate from boys, but provide water, soap, supplies for menstrual management, and privacy from other girls as well as boys. Where this is being implemented, for example with UNICEF’s support, the evaluations have not been able to distinguish the relative effects of single components.

Menstrual management in schools

Where absenteeism is evident, it appeared that menstruation can serve as both a:

• pull out factor, if girls do not attend school because of menstrual pain or family/cultural expectations to stay home, or where menarche leads to early sex, pregnancy, and/or marriage; or
• a push out factor, whereby girls avoid or miss school because of inadequate facilities to manage their menstruation.

It is in the latter case whereby facilities at school (specifically separate toilets for girls) may reduce absenteeism. The authors did not identify any studies that showed an impact of separate toilets on menstrual management (and consequently kept girls in school). However, two studies claimed benefits of their WASH intervention. In the evaluation of SSHE in Kerala, India, girls in the control schools were more likely than girls in the intervention schools to report problems using facilities during menstrual periods (52% vs 25%, p<0.001), although the specific nature of those problems was not mentioned. And, in the 6-country pilot study of UNICEF’s SSHE, one country reported that “girls, who used to be absent during their menstrual period, seem to show improved school attendance.” The authors continue, “However, hard data was not available. This deserves better study in the future” (UNICEF/IRC 2006).

IRC-related references

Bolt E, Shordt K, Krukkert I. School sanitation and hygiene education results from the assessment of a 6-country pilot project. UNICEF and IRC International Water and Sanitation Centre, the Netherlands, 2006.

IRC International Water and Sanitation Centre (2004) Symposium Proceedings and Framework for Action. School sanitation and hygiene education symposium. The Way Forward: Construction is not enough, Delft, The Netherlands 8-10th June 2004.

IRC International Water and Sanitation Centre (2006). Girl friendly toilets for Schoolgirls

Raising Clean Hands (2010). Advanced Learning, Health and Participation through WASH in Schools: Joint Call to Action 2010. CARE, Dubai Cares, Emory University Center for Global Safe Water, IRC International Water and Sanitation Centre, Save the Children, UNICEF, Water Advocates, WaterAid, Water for People, WHO.

Snel M (2004.) Worth of School Sanitation and Hygiene Education (SSHE): Case studies (draft). Delft: IRC.

Snel M (2003). School sanitation and hygiene education. In: Snel Marielle, Maier Cecilia, Wijk Christine van; Postma Leonie . Delft: IRC, pages .

Snel M, Bolt E, Postma L (2000). Challenges facing school sanitation and hygiene education from the perspective of the school teacher. Waterlines. 19(1): 25-28.

Snel M, Shordt K (2005). The evidence to support hygiene, sanitation and water in schools. Waterlines. 23(3).

Visscher JT, Garcia M, Madera C, Benavides A, Quiroga E (1996). Out of the mouths of babes: an honest evaluation of water and sanitation in Ecuador. Waterlines. 14(3): 19-22.