Effectiveness of a Multi-Component School-Based Educational Intervention on Improving Water, Sanitation, and Hygiene (WASH) Practices among Primary School Children in Rawalpindi: A Randomized Controlled Trial

To evaluate the effectiveness of a multi-component school-based Water, Sanitation and Hygiene (WASH) intervention in improving observed handwashing with soap (HWWS), WASH-related knowledge, attitudes and practices (KAP), and reducing illness-related absenteeism among primary school children in peri-urban Rawalpindi, Pakistan.

Two-arm parallel-group cluster randomized controlled trial with school-level randomization, usual-care control, and assessor-blinded outcome assessment.

Public primary schools in the peri-urban areas of Rawalpindi District, Pakistan. Schools were randomized to intervention or control groups. Assessments were performed at baseline, immediately after the intervention, and at 3-month follow-up.

Inclusion criteria: Children aged 6–12 years enrolled in grades 2–5 at selected public primary schools, with written parental/guardian consent, child assent, and school approval. Exclusion criteria: Students with cognitive or sensory impairments affecting participation, >50% absenteeism during baseline or intervention, enrollment after randomization, or those outside the target age group or grades.

Participants received a 4-week multi-component WASH intervention comprising interactive hygiene education, continuous soap provision, environmental behavioral nudges (painted footprints and mirrors), and student-led WASH committees to reinforce handwashing behavior.

Observed handwashing with soap (HWWS) behavior, measured using a structured non-intrusive observation (SNIO). Secondary outcomes included WASH KAP scores, illness-related absenteeism, and sustainability of handwashing behavior at 3 months.

A simple cluster randomization method with a 1:1 allocation ratio was used, with the school serving as the unit of randomization to minimize contamination between students within the same institution. Eligible public primary schools from the selected peri-urban areas of Rawalpindi were assigned unique identification numbers, and an independent researcher generated the random allocation sequence using a computer-generated random number function in Microsoft Excel. No stratification was applied because all participating schools had comparable geographical and administrative characteristics. Allocation concealment was maintained until completion of baseline data collection by restricting access to the allocation sequence to the independent researcher. Owing to the nature of the intervention, blinding of participants and school staff was not feasible; however, outcome assessors remained blinded to group allocation during data collection to minimize observer bias.

Owing to the nature of the multi-component school-based intervention, blinding of participants, teachers, and intervention providers was not feasible. However, outcome assessors were blinded to group allocation during baseline, post-intervention, and follow-up data collection to minimize observer bias. Thus, the study employed an assessor-blinded (single-blind) design.

De-identified Individual Participant Dataset (IPD) and Study Documents De-identified individual participant data underlying the published results, including the study protocol, statistical analysis plan, data dictionary, informed consent forms, and study instruments (WASH KAP questionnaire and Structured Non-Intrusive Observation checklist), will be made available upon reasonable request to the corresponding investigator. Data will be shared after publication of the primary study findings for researchers with a methodologically sound proposal, following approval by the principal investigator and institutional ethics requirements. Participant confidentiality will be protected by removing all personal identifiers.

By December 2026

All the people related to public health

For public health issues related to hand hygiene

by emailing the Dr Paaras Suleman : Dr Paaras Suleman sulemanpaaras@gmail.com 0334-3931815

Researchers requesting access to study data or documents should submit a written request to the corresponding investigator describing the research objectives, intended use of the data, and analysis plan. Requests will be reviewed by the principal investigator and, where required, the institutional ethics committee to ensure scientific merit and protection of participant confidentiality. Approved applicants may be required to sign a data-sharing agreement before receiving de-identified data and study documents. Data will normally be made available within 4–8 weeks of approval.