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A blog that mentions events in which people help NC communities. Clean water for North Carolina (CWFNC) is a nonprofit organization. The goal of the organization is to promote clean, safe, and empowered water. The communities advocate educational technical assistance. They have offices in Durham and Asheville.

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EMPOWERED, JUST COMMUNITIES CWFNC is committed to working for environmental justice through community organizing, collaboration with other NC Environmental Justice Network partners, technical assistance and training. Goals: Provide effective, accountable organizing and technical assistance, especially to people-of-color, low-income and rural communities, to increase knowledge, skills, and action to protect human health and community environments.

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This article discusses the challenges facing water-related ecosystems. There are societies that impact our water-related ecosystems. The was a loss about 40% of our global wetlands. This is just one of the impacts of some of the impacts human have on our environment.

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In 2015, the United Nations announced the adoption of 17 SDGs and 169 targets which aim to "Transform our world". People are calling this the most important and largest global undertaking that will shape the world until 2030 and beyond. Under the banner of sustainable development, the SDGs merge the needs of humans and the environment under one global agenda that is designed to ensure the future of society and planet. Supporting sustainable development therefore requires societies to work together to meet these needs.

The world is currently facing a daunting double challenge: human populations and material demands are increasing while natural resources are declining at an alarming rate. The SDGs are therefore designed to provide transparency, information, and data on just about every possible aspect that reflects society's attempts to live in a sustainable way. This is done through the SDG indicator framework which tracks and reports progress towards sustainable development.

Challenges facing water-related ecosystems

In pursuit of development, societies across the globe have negatively impacted water related ecosystems. A shocking example of this is that the rate of loss of global wetlands between 1900 and 2000 is estimated to be around 69-75% (Davidson 2014, see Figure 1). 40% of the loss occurred between 1970-2008, according to the 2015 Ramsar Convention on Wetlands. Increased water abstraction for growing urban populations was partly to blame, as was the transformation of wetlands - lands saturated by water, such as marshes or river deltas - into arable agricultural land.

Wetlands are in fact one of the most productive ecosystems that provide many of the services that society depends on, ranging from provision of food and water, regulation of flows of water, recycling of nutrients and waste,and cultural benefits, such as spiritual, recreational or educational uses.

Figure 1 illustrates the rate of decline of wetlands. Given the importance of these ecosystems, a massive global effort is required to restore and protect them, and for this the SDG 6.6.1 Indicator method seeks to collect the necessary information. But a significant question remains: what are the best ways to gather and assess this data?

Water-related ecosystems and the SDGs

Water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers, and lakes, are vital to providing social and economic benefits for people. The declining condition of the ecosystems directly impacts water availability as well as other essential services such as biodiversity, food production and flood control. For that reason, Target 6.6 - By 2020, protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers and lakes - is set to contribute to the achievement of Goal 6. In service of that, indicator 6.6.1 - Change in the extent of water-related ecosystems over time - and its component sub indicators, will be used to monitor management performance in relation to the target.

How are water-related ecosystems monitored for the SDGs?

Monitoring of Target 6.6 represents what could become the world's largest initiative to monitor and report on water-related ecosystems. This builds substantially on the monitoring of the spatial extent of wetlands that has been developed by the Ramsar Convention of Wetlands by including measures of quantity, quality and ecosystem health.

A report published by IWMI and WLE provides guidance to countries on the method used for reporting SDG Indicator 6.6.1, which monitors the "change in extent of water-related ecosystems over time." This guideline supports the abbreviated but official UN Water indicator monitoring method.

The aim of the guideline is to support countries by:

teaching them to collect and submit data on SDG 6.6.1 as part of their contribution to sustainable development

providing guidance on the methods used to monitor water-related ecosystems

supporting the management of water resources at a country level.

The guideline responds to each of the sub-indicators illustrated in Figure 3. Guidance is given for monitoring the spatial extent of water-related ecosystems such as vegetated wetlands, rivers and open water bodies such as lakes, artificial reservoirs, and groundwater aquifers. A large part of this guidance is devoted to techniques that use Earth Observation data to measure change in extent (see the iconic example in Figure 4, showing the loss in extent of the Aral Sea which is a freshwater lake).

The amount of water stored in a given ecosystem is another key indicator of ecosystem health. Quantity is thus reported for rivers and other open water bodies, like lakes and reservoirs, as well as for groundwater. In addition, monitoring the quality of water over time is crucial for determining any potential negative impacts to the ecosystem and thus to the many services provided by the ecosystem. Lastly, the state or health of the ecosystems is monitored through a system that evaluates the biota (e.g. fish, invertebrates or vegetation) as indicators of overall ecosystem condition. This process of measuring changes in the biotic communities helps society to detect overall changes to the ecosystem (see figure 5 for illustration).

The inclusion of Indicator 6.6.1 as part of the SDG Agenda represents a wonderful opportunity for society to gather and make use of data reflecting the state of water-related ecosystems. This will enable us to better manage these ecosystems in order to secure a sustainable future. The SDG 6.6.1 step-by-step method is in the process of being implemented globally as part of the Agenda 2030, and this guideline provides much-needed support to those who are involved in this submission or who wish to understand the measures necessary to achieve sustainable development.

Blog Post

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Podcast

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Podcast

CGIAR Research Program on Water, Land and Ecosystems (WLE). 2016.WLE's contributions to the SDGs.CGIAR Research Program on Water, Land and Ecosystems (WLE).5p.

CGIAR Research Program on Water, Land and Ecosystems (WLE). 2015. Putting ecosystems into the SDGs. Colombo, Sri Lanka: CGIAR Research Program on Water, Land and Ecosystems (WLE). 5p.

Griggs, D.J.; Nilsson, M.; Stevance, A.; McCollum, D. (eds.). 2017. A guide to SDG interactions: From science to implementation. Paris, France: International Council for Science (ICSU).

Dickens, C., Rebelo, L-M., and Nhamo, L. (2017) Guidelines and indicators for Target 6.6 of the SDGs: Change in the extent of waterrelated ecosystems over time. Report by the International Water Management Institute. CGIAR Research Program on Water, Land and Ecosystems (WLE). 44p.

Amarnath, Giriraj. 2019. Bundled Solutions of Index Insurance with Climate Information and Seed Systems to manage Agricultural Risks (BICSA). Colombo, Sri Lanka: International Water Management Institute (IWMI). CGIAR Research Program on Water, Land and Ecosystems (WLE). 2p.

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The SDGs target protection of water-related ecosystems, but how do we measure progress?

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In 2015, the United Nations announced the adoption of 17 SDGs and 169 targets which aim to "Transform our world". People are calling this the most important and largest global undertaking that will shape the world until 2030 and beyond.

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This document digs in deeper into the ecosystems. Water is vital for our human health and well-being. The document below repots under the United Nations, progress towards the global goal 6 (Clean water and sanitation). This document is part of a series that tracks the progress on country data from other resources.

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The Public Water Supply Section is responsible for regulating the public water systems. Public water systems is provided by piped drinking water. There is about 6,000 public water systems in the State of NC.

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It is the responsibility of the Public Water Supply Section to regulate public water systems within the state under the statutory authority of G.S. 130A Article 10. Public water systems are those which provide piped drinking water to at least 15 connections or 25 or more people 60 or more days per year.

There are nearly 6,000 regulated public water systems in the state. About three-fourths of the state's population lives in areas served by community water systems. Other people are served by different types of public water systems, such as workplaces, schools, parks or restaurants.

The section has branches and programs for:

Implementation of the mandates of the federal Safe Drinking Water Act;

Review and approval of plans and specifications for new and expanding or improving water systems;

Inspections, investigations, and technical assistance for water systems;

Emergency responses and complaint investigations;

Source water assessment, protection, and wellhead protection;

Capacity development; and

Administration of an operating fee permit program.

In the absence of these responsibilities, the consuming public would be subjected to risks such as drinking contaminated water and having substandard drinking water facilities.

Mission

To promote public health by ensuring that safe, potable water is available in adequate quantities to the residents and visitors of North Carolina served by public water systems by assuring that such systems are properly located, constructed, operated, and maintained.

Vision

North Carolinians are consistently served a safe, reliable supply of drinking water by compliant water systems.

Contact Us

Mailing Address
Public Water Supply Section
Division of Water Resources
1634 Mail Service Center
Raleigh, NC 27699-1634

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It is the responsibility of the Public Water Supply Section to regulate public water systems within the state under the statutory authority of G.S. 130A Article 10. Public water systems are those which provide piped drinking water to at least 15 connections or 25 or more people 60 or more days per year.

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After many protests, meetings, and lawsuits, the cape fear public authority finally declared that the water is safer to drink than it was two years ago. It was two years ago that the chemical compound was found in the drinking water in the Cape Fear River. This caused dangerous conditions for the public and made people think twice about drinking from their faucets.

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WILMINGTON, N.C. (WECT) - It has been two years since news broke that the chemical compound known as GenX was found in the drinking water of thousands of people in the Cape Fear region. This unknown contaminant sparked fear and outrage across the area.

Two years and countless meetings, protests, water samples, and lawsuits later, the Cape Fear Public Utility Authority says the water is far safer to drink than it was before GenX started making headlines.

"It's been two years but we've accomplished a lot in two years," said Jim Flechtner, the executive director of CFPUA. "We've seen the levels of these contaminants produce not only in the river, but also in the finished water that we are drinking. We're taking steps so that our plant can filter these compounds from our drinking water very effectively."

After calls from the community and political leaders, the North Carolina Department of Environmental Quality has been forced to hold Chemours, the company responsible for dumping the chemical into the the Cape Fear River, responsible.

"We're taking legal action against Chemours because we believe our customers shouldn't pay for this. And we're also working with the state because the real answer to this is that these contaminants shouldn't be in the environment to begin with," Flechtner said.

Flechtner said the true answer to the ongoing problems is to have proper regulation and proper enforcement on a state level. Despite that, he said, CFPUA tests the drinking water before and after it is treated on a weekly basis.

"Our water is cleaner than it used to be. We understand where these contaminants are coming from, and we've taken steps to stop it. We're also holding those accountable through legal action who have put these contaminants in the environment.

Two years ago, the levels of GenX and other toxic chemicals were estimated to be about 130,000 parts per trillion. Currently, levels of GenX in the river are measuring at 150 parts per trillion, Flechtner said.

"Because of some of our work at our plant, we're reducing that to about 60 parts per trillion in the finished water. So levels are down considerable. They have never have been that high to begin with, but the good news is we've been able to bring them down," he said.

Throughout the past two years, community activists have attended forums and meetings, demanding clean water. Those efforts are finally paying off.

"Our community is very engaged and that's a great thing. The more active our customers are the more active our community is, the better results we're going to get. So it's encouraging to see all the grassroots efforts, the political efforts, regulatory efforts to bring the best water for this community. So while our focus is changed, I think we all understand where these compounds are coming from, from the upstream discharges and holding them accountable and responsible for what's happened is important. And it's very rewarding for me to see so many people in our community working on this issue," Flechtner said.

In the next two years, the Sweeney Water Treatment Plant will receive a granular activated carbon filter to remove more GenX and other contaminants from the drinking water.

"We're finishing up design on the granular activated carbon filters we added to our Sweeney Water Treatment Plant that will bring these levels down even further. So the water will be significantly cleaner. And it's another barrier of protection. We can't rely on these upstream companies to tell us what they're putting in the river," he said.

Copyright 2019 WECT. All rights reserved.

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Two years later, where do we stand on GenX?

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It has been two years since news broke of GenX found in the drinking water. This unknown contaminant sparked fear and outrage across the Cape Fear. Two years, countless meetings, protests, water samples, and lawsuits later, the Cape Fear Public Utility Authority says the water is far safer to drink

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The residents of North Carolina have been driving contaminated water for decades. The author of this news article talks about the recent causes of GenX spikes in the Cape Fear River. Heavy rainfall from storms caused run-off from a company who has been discharging GenX into the water since 1980.

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WILMINGTON, NORTH CAROLINA - It's hard to miss the piles of tree branches, logs, and other debris that line the streets of Wilmington. Local business posters are clustered at the main intersections advertising repairs and help with water damages. It's been five weeks but the remnants of Hurricane Florence are everywhere.

When the storm hit on September 14, it turned this eastern North Carolina town into an island. Coal ash spills were reported just outside the town and six hog waste lagoons were damaged, spilling excrement into the rivers and setting off alarm bells among residents. Wilmington is no stranger to water contamination.

"All of the issues and challenges that North Carolina faced before the storm, still exist and many have been exacerbated," Deb Butler, Democratic candidate for North Carolina house district 18, told ThinkProgress.

Florence made a difficult situation even worse. Residents are tired of not knowing what health risks they might be facing after years of drinking contaminated water. And now, with the midterm elections just weeks away, they have a chance to vote for candidates who might finally do something about it.

"One of the things that's crystal clear," Butler said, "is that we had in this region of eastern North Carolina a water quality problem, GenX. And now you can add coal ash and hog manure into the cocktail. So, the problems that we had before the storm are just worse now."

GenX, as it's known, is a potentially cancer-causing chemical. It is the byproduct from the manufacturing of vinyl ethers at the local Chemours' plant - a DuPont subsidiary - located on the Cape Fear River in Fayetteville, about 100 miles upstream from Wilmington.

Some 60,000 Wilmington residents rely on the Cape Fear River for their drinking water. In June 2017, the Wilmington Star-News reported that GenX was being released by Chemours' Fayetteville Works into the river; even worse, the utilities drawing water from that same river were unable filter it out.

While the human health impacts of drinking water laced with GenX are still unclear, studies conducted by DuPont and submitted to the Environmental Protection Agency (EPA) show it causes tumors and reproductive issues in lab animals.

According to local news outlets, the EPA has been aware of the toxic chemicals in the Cape Fear River since at least 2006, and its presence in drinking water since 2013. The public, however, was not alerted until 2017.

Residents have been drinking contaminated water for decades. Last year, a DuPont official acknowledged during a meeting that the company had been discharging GenX into the river since 1980. While the state's restrictions have brought GenX levels down below the required 140 parts per trillion limit, heavy rain can sometimes result in runoffs from the plant, spiking GenX levels.

GenX isn't the only concern for Wilmington-area residents; there's also the suspected carcinogen C8, GenX's predecessor, as well as per- and polyfluoroalkyl substances better known as PFOS and PFOA - and all are believed to be originating from the Chemours plant. DuPont has previously said GenX is safer than C8.

"We drank GenX for 30 years without knowing it, and I want to know what we're drinking now," Leslie Cohen, Democratic candidate for state house district 20, said.

All of the local candidates who spoke with ThinkProgress agreed that water quality is the top concern for many Wilmington-area voters this year. Residents want clear communication regarding contaminants in their water and their resultant level of risk. They cite the need for more rigorous testing and the establishment of baseline safety levels.

And Hurricane Florence's destruction only intensified the simmering tension over the area's contaminated water and what's being done to address it.

Cohen only realized the full extent of the region's water quality issues after attending a small public talk with local experts. "I was the only person in the room who was not a scientist," she said.

"When I heard the scientists talk, I heard fear from the scientists. And I said, okay I need to be worried," she told ThinkProgress. "You don't hear scientists scared very often, and there was real worry there."

For those who can afford it, the fix is to either drink bottled water exclusively or to buy a reverse osmosis device that attaches to the kitchen faucet and filters out the chemicals. Some residents are even using bottled water for their dogs.

Jeannie Lennon, a Wilmington resident and a grandmother of seven, has been helping a group of Democrats who have all been endorsed by the Sierra Club for their strong positions on water quality. She knocks on doors, volunteers at the polls, and calls everyone she knows asking them to vote. Clean water is "huge" in the community, she said.

"It's been a quadruple whammy," she told ThinkProgress of the chemicals, coal ash, and animal waste that spilled from both Florence and Hurricane Matthew two years ago.

Lennon was part of a research study to test whether people have been affected by GenX. Her urine and blood were tested but she's still waiting on the results. "I haven't gotten that back, which worries me," she said. "It's been a long time, almost a year I think. We should've known something by now."

But her fears aren't just for her own well-being. "I'm concerned that my grandchildren, who all live here, are drinking this water and have grown up drinking it," she said. "And I don't know what long-term impact that's going to have on them."

The safety of the drinking water in local schools is a major worry for local parents. More affluent schools are able to afford bottled water; parents will regularly organize donation drives at the beginning of the school year to gather enough bottled water for each semester.

But in areas where families can't afford the time or money to organize and donate the necessary amount of bottled water, children drink from potentially contaminated water fountains. It's "an economic injustice," Marcia Morgan, Democratic candidate for state house district 19, told ThinkProgress.

"This isn't something you can boil out of the water, that's not an option," Morgan said. "You have to have it go through some sort of purification system or come from a different source, and that's expensive. There is no cheap fix for the less affluent to be able to tap into."

Morgan believes that in addition to better testing methods, corporations need to be held to a higher standard. At the first sign of any kind of violation, she said, the plant should be shut down. "I think that gets their attention," she said; fines alone don't seem to act as a strong deterrent.

But, "we have to have the political will to do that," Morgan added.

In May, the state senate introduced the Water Safety Act with the aim of setting better water quality standards and stricter contamination rules (the bill has yet to pass). The proposal was quickly criticized by Democrats, the North Carolina Department of Environmental Quality (DEQ), and some news outlets for not doing enough to tackle the GenX problem.

Cohen, for instance, criticized the state's Republican Party for having "actively worked to protect polluters," specifically for adopting Chemours' desired changes. Morgan, meanwhile, has questioned why the state legislature has done so little to address GenX contamination over the past year.

An editorial by the Fayetteville Observer took the bill's Republican sponsors to task, arguing that the measure would make enforcement against Chemours more difficult and reduce the authority of the state DEQ.

Efforts to address water contamination "will all but grind to a halt," the Observer's editorial warned. "The Senate has once again put its deregulation mania ahead of public safety. We hope the voters are taking notice in this election year."

It seems some voters are paying close attention. Water quality is a "very major concern," said Michael Mallin, a research professor at the Center for Marine Science at the University of North Carolina at Wilmington. Was it a deciding factor in how he voted this election cycle? "Absolutely."

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North Carolina water quality becomes major campaign issue before midterms

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WILMINGTON, NORTH CAROLINA - It's hard to miss the piles of tree branches, logs, and other debris that line the streets of Wilmington. Local business posters are clustered at the main intersections advertising repairs and help with water damages. It's been five weeks but the remnants of Hurricane Florence are everywhere.

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The United Nation coordinated the observance on fresh water sanitation. The campaign is usually led by one or multiple members of the UN. One campaign is called "World Water Day." This article goes into depth about what the campaign entails and its purpose.

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United Nations Observances

The United Nations observes designated days, weeks, years, and decades, each with a theme, or topic.

By creating special observances, the United Nations promotes international awareness and action on these issues. The majority of observances have been established by resolutions of the United Nations General Assembly, although some have been designated by UN specialized agencies.

The United Nations also observes anniversaries of key events in its history.

More about the United Nations Observances.
Official themes and previous campaigns
2020: World Water Day - Climate Change

2019: World Water Day - Leaving No One Behind (Human Rights and Refugees) | World Toilet Day - Coordinators: OHCHR, UNHCR, Task Force: Aquafed, UN Global Compact, FAO, ILO, SWA, UCLG, UNCCD, UNDP, UNESCO, UN Habitat, UNICEF, UNU, UN Women, Water Lex, WSSCC

2018: World Water Day - Nature for Water - Coordinators: CBD, UN Environment, UNESCO | World Toilet Day - When nature calls - Coordinators: WSSCC, UNDP, UNICEF UNU, WHO, ILO | Water Action Decade

2018: Launch of the Water Action Decade 2018-2028

2017: World Water Day - Wastewater | World Toilet Day - Wastewater - Coordinators: UNEP, UN Habitat, UNU, WHO

2016: World Water Day - Water and Jobs | World Toilet Day - Toilets and Jobs - Coordinator: ILO

2015: World Water Day - Water and Sustainable Development - Coordinator: UNDP | World Toilet Day - Toilets and Nutrition - Coordinator: UNICEF

2014: World Water Day - Water and Energy - Coordinators: UNIDO, UNU | World Toilet Day - Equality and Dignity - Coordinators: UNU, UN Habitat

2013: World Water Day - Water Cooperation - Coordinator: UNESCO

2012: World Water Day - Water and Food Security - Coordinator: FAO

2011: World Water Day - Water for Cities - Coordinator: UN Habitat

2010: World Water Day - Water Quality

2009: World Water Day - Transboundary Waters - Coordinators: FAO, UNECE, UNESCO

2008: World Water Day - International Year of Sanitation - Coordinator: UNDESA

2007: World Water Day - Water Scarcity - Coordinator: FAO

2006: World Water Day - Water and Culture - Coordinator: UNESCO

2005: World Water Day - Water for Life 2005-2015

2004: World Water Day - Water and Disasters - Coordinators: UNISDR, WMO

2003: World Water Day - Water for the Future - Coordinator: UN Environment

2002: World Water Day - Water for Development - Coordinator: IAEA

2001: World Water Day - Water for Health, Taking Charge - Coordinator: WHO

2000: World Water Day - Water for the 21st Century

1999: World Water Day - Everyone lives downstream - Coordinator: UN Environment

1998: World Water Day - Groundwater, the invisible resource - Coordinators: UN DESA, UNICEF

1997: World Water Day - The World's Water, Is There Enough?

1996: World Water Day - Water for Thirsty Cities

1995: World Water Day - Women and Water

1994: World Water Day - Caring for Water Resources is Everybody's Business

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United Nations Observances The United Nations observes designated days, weeks, years, and decades, each with a theme, or topic. By creating special observances, the United Nations promotes international awareness and action on these issues. The majority of observances have been established by resolutions of the United Nations General Assembly, although some have been designated by UN specialized agencies.

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The United Nations International Children's Emergency (UNICEF) was established to meet the needs of children. Climate change affects over 175 million children allover the world. People from all over the world are coming together to support the needs of children such as water, sanitation, and hygiene conditions.

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UNICEF | Children's Rights & Emergency Relief Organization

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Clean water, basic toilets and good hygiene practices are essential for the survival and development of children. Today, there are around 2.4 billion people who do not use improved sanitation, and 663 million who do not have access to improved water sources.

Without these basic needs, the lives of millions of children are at risk. For children under five, water- and sanitation-related diseases are one of the leading causes of death. Every day, over 800 children die from preventable diseases caused by poor water, and a lack of sanitation and hygiene.

UNICEF's water, sanitation and hygiene (WASH) team works in over 100 countries worldwide to improve water and sanitation services, as well as basic hygiene practices. Last year, UNICEF's efforts provided nearly 14 million people with clean water and over 11 million with basic toilets.

In times of crisis children are particularly vulnerable; UNICEF responds and provides emergency relief to those in need.

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Clean water, basic toilets and good hygiene practices are essential for the survival and development of children. Today, there are around 2.4 billion people who do not use improved sanitation, and 663 million who do not have access to improved water sources. Without these basic needs, the lives of millions of children are at risk.

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Groundwater Awareness Week is through March 10th-16th and emphasizes how groundwater is necessary for our ecosystems’ survival. It is a time where people can celebrate water and appreciate its many benefits. This article describes the importance of this week and why people should not take it for granted.

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GROUNDWATER FOUNDATION DAY

Without groundwater, life would be impossible. We use it for drinking, irrigation, livestock, manufacturing, mining, thermoelectric power, and a whole lot more, making it one of the most widely used and valuable natural resources on Earth.

During National Groundwater Association's Groundwater Awareness Week, March 10-16, 2019, you can help protect groundwater.

Make a tax-deductible donation to the Groundwater Foundation of $75 or more anytime during Groundwater Awareness Week (use the form below) and be entered to win a prize package to the 2019 College World Series and Henry Doorly Zoo and Aquarium in Omaha, Nebraska.

The more you donate, the better your chances of winning:

$75-99 donation = 1 entry

$100-149 donation = 5 entries

$150 or more donation = 10 entries

Learn more about the prize packages and donate here.

On Groundwater Foundation Day - Friday, March 15 - a winner will be chosen at random, notified immediately, and featured on social media.

Good luck - and THANK YOU for being part of the solution for clean, sustainable groundwater!

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Without groundwater, life would be impossible. We use it for drinking, irrigation, livestock, manufacturing, mining, thermoelectric power, and a whole lot more, making it one of the most widely used and valuable natural resources on Earth. During National Groundwater Association's Groundwater Awareness Week, March 10-16, 2019, you can help protect groundwater.

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Water has many benefits for the human body so it is important to be filling the body with clean water. This article describes why water is essential for human health. For example, it helps fight off illness and aids digestion. The bottom line is that water is vital for every part of the human body.

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Why Is Water Important? 16 Reasons to Drink Up

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Not only does water make up most of your weight, it’s involved in many important functions. See how water improves your overall well-being.

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DuPont and Chemours plant is located upstream from the cape fear river. The Wilmington residents fear that the these plants are dumping a dangerous chemical, GenX, which is potentially cancer inducing.

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N.C. drinking water tainted with chemical byproduct for decades?

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Some 60,000 Wilmington, N.C., residents get their drinking water from the Cape Fear River. DuPont and its spinoff company Chemours manufacture chemicals at a plant upstream from the city. The plant is situated on a 2,100-acre property on the Cape Fear River in Fayetteville.

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Schools in low-income countries have inadequate water systems creating unsafe situations for the children. These facilities directly affect the children’s health and, thus, their attendance in school. This article provides statistics and facts about the causes and effects of poor water facilities in low income schools.

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Abstract

Many schools in low-income countries have inadequate access to water facilities, sanitation and hygiene promotion. A systematic review of literature was carried out that aimed to identify and analyse the impact of water, sanitation and hygiene interventions (WASH) in schools in low-income countries. Published peer reviewed literature was systematically screened during March to June 2018 using the databases PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google Scholar. There were no publication date restrictions. Thirty-eight peer reviewed papers were identified that met the inclusion criteria. 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. The typically unmeasured and unreported 'output' and/or 'exposure' of program fidelity and adherence was also examined. Several studies provide evidence of positive disease-related outcomes among students, yet other assessments did not find statistically significant differences in health or indicated that outcomes are dependent on the nature and context of interventions. Thirteen studies provide evidence of changes in WASH knowledge, attitudes and behaviours, such as hand-washing with soap. Further research is required to understand whether and how school-based WASH interventions might improve hygiene habits and health among wider family and community members. 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. While further rigorous research will be of value, political will and effective interventions with high program fidelity are also key.

Keywords: water, sanitation, hygiene, WASH, schools, intervention

1. Introduction

Schools with adequate water, sanitation and hygiene (WASH) facilities have: a reliable water system that provides safe and sufficient water, especially for hand-washing and drinking; sufficient number of toilets for students and teachers that are private, safe, clean, and culturally and gender appropriate; water-use and hand-washing facilities, including some close to toilets; and sustained hygiene promotion [ 1]. Facilities should cater to all, including small children, girls of menstruation age, and children with disabilities. WASH conditions in schools in many low-income countries, however, are inadequate with associated detrimental effects on health and school attendance [ 2]. An evaluation by UNICEF [ 3] found that in schools in low-income countries, only 51% of schools had access to adequate water sources and only 45% had adequate sanitation.

Globally, school-based WASH interventions variously aim to: (i) reduce the incidence of diarrhoea and other hygiene related diseases; (ii) improve school enrolment, school performance, and attendance; and (iii) influence hygiene practices of parents and siblings whereby children act as agents of change in their households and communities. However, evidence assessing the impact of school-based WASH interventions has been mixed. Two previous reviews of studies of the impact of school-based WASH interventions have shown mixed results on outcome measures such as knowledge, attitudes and practices, school attendance, and health [ 2, 4]. The review by Jasper et al. [ 2] had a global focus and most included studies ( n = 41) were from high- and middle-income countries (e.g., United States, United Kingdom); Joshi and Amadi [ 4] also had a global focus including studies from North America and Europe and their review was confined to studies ( n = 15) published between 2009-2012.

The objective of this review is to analyse published peer-reviewed journal articles that focus on WASH in schools in low-income countries. The review focuses on intervention-based studies and key outcome measures including: health among school students (e.g., diarrhoeal disease and other hygiene-related diseases); WASH knowledge, attitudes and hygiene behaviours among students; changes in disease burden and hygiene behaviours in students' households and communities; changes in student enrolment and school attendance. The review also considers the under-reported indicator of intervention fidelity. The review highlights gaps in knowledge and potential future research directions.

2. Materials and Methods

Published peer reviewed journal articles were included that examined the impacts of school-based WASH intervention in low-income countries. WASH interventions included: hand-washing initiatives (e.g., water, wash basins, soap, drying devices); drinking water initiatives; improved sanitation (improved toilets, facilities for menstruation); and hygiene behaviour initiatives (e.g., handwashing with soap, hygiene education). Reported outcomes include: educational outcomes (i.e., school attendance, school dropout); hygiene behaviours, knowledge and attitudes; and health (i.e., WASH-related illness). Intervention fidelity-adherence to intervention delivery standards-was also reported in several studies (either as an 'exposure' or 'outcome'). Article inclusion was restricted to those with a focus on low-income countries, defined as countries with a Gross National Income (GNI) per capita (calculated using the World Bank Atlas method) of 1005 USD or less in 2016. The review was restricted to articles for which the abstract and article was available in English language.

Descriptive studies of school-based WASH conditions, without evaluative focus on intervention impacts, were excluded [ 5, 6]. Morgan et al. [ 5], for example conducted a cross-sectional survey of 2270 WASH intervention beneficiary schools in Ethiopia, Kenya, Mozambique, Rwanda, Uganda and Zambia and found that fewer than 23% of rural schools met World Health Organization recommended student-to-latrine ratios. While descriptive studies provide important insight into the context and challenges for WASH in schools, they are not the focus here.

The following electronic databases were searched during March to June 2018: PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google Scholar. The search was based on the keywords: WASH or water or sanitation or soap or hygiene or "hand hygiene" or "hand wash*" AND school or attendance AND "low income" or "developing country" or "developing nations". For example, in Embase the following search terms were deployed: (WASH OR water OR hygiene OR "hand hygiene" OR "hand wash*" OR sanitation OR Soap* OR "child* health") AND (school OR attendance) AND ("low income country" OR "developing country"). References of included articles were systematically searched for relevant documents. There were no publication date restrictions.

3. Results

3.1. Systematic Review and Yielded Studies

The initial search terms identified 1498 publications; 11 additional articles were identified from other sources. The secondary screening-based on the title-identified 119 articles with a potential focus on WASH in schools in low-income countries. Thirty eight of these articles met the inclusion criteria, following screening by abstract and then full text. Bibliographies of these references identified no additional articles (see ).

For each article, a summary of key information was tabled: i.e., country of study, study design, study population (number of schools, children, and/or their age), exposure/intervention, outcome measure, key findings. As the studies use diverse methods and outcome measures no attempt was made to weight the value of findings according to study quality, or to conduct meta-analysis of study findings. Of the 38 articles: 47% reported the intervention impact on diarrhoeal disease and other hygiene-related diseases in school students; 34% reported changes in WASH knowledge, attitudes and hygiene behaviours among students; 16% reported impact on disease burden and hygiene behaviours in students' households and communities; 32% reported changes in student enrolment and school attendance; and 11% reported on intervention fidelity (see ). Twelve studies reported outcome measures across more than one category [ 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18] (see ).

Countries of focus included Bangladesh, Burkina Faso, Cambodia, China, Colombia, Egypt, Ethiopia, Ghana, India, Indonesia, Kenya, Lao People's Democratic Republic, Mali, Niger, Nepal and Tanzania. Study methods included cross-sectional survey, non-randomized trial, cluster-randomized trial, and before and after intervention studies. Study design is identified in .

3.2. Reduced Diarrhoea and other WASH-Related Diseases in School Students

Despite the biological plausibility that improvements in school WASH conditions will be beneficial for pupil health, results from school-based WASH evaluations have been mixed. There is evidence that WASH in Schools programs have a positive impact on child health, including reductions in diarrhoeal disease and other hygiene-related diseases. Migele et al. [ 28] examined the impact of a simple school-based water treatment and hand-washing intervention in a boarding school in Kenya: i.e., clay pots modified with narrow mouths and ceramic lids, taps for drinking water, plastic tanks with taps for hand washing, WaterGuard (i.e., sodium hypochlorite solution) for drinking water, and soap for hand washing. Before-and-after rates of diarrhoea disease (with no control schools) indicated a more than 50% reduction in recorded cases of diarrhoea among students. In their evaluation of WinS interventions in Mali, Trinies et al. [ 18] found that, as compared with control schools, there were lower odds of students in beneficiary schools reporting diarrhea (OR 0.71, 95% CI 0.60-0.85) or respiratory infection symptoms (OR 0.75, 95% CI 0.65-0.86) in the past week. And a study in rural Kenya [ 15] found that school-based water treatment and hygiene programs resulted in a decrease in rates of acute respiratory illness, although no decrease in acute diarrhea was observed. Improving school-based WASH can also reduce other hygiene-related diseases, such as soil-transmitted helminth (STH) infection [ 7, 21, 22]. For example, Bieri et al. [ 7] found that among Chinese school-children, the incidence of infection with STHs was 50% lower in the intervention group that received a STH education package than in the control group (4.1% vs. 8.4%, p < 0.001). And in Mali, Freeman et al. [ 22] found that provision of school-based sanitation, water quality, and hygiene improvements reduced reinfection of some STHs after school-based deworming, but the magnitude of the effects were helminth species-specific.

Results, however, are not uniformly clear or positive. In an evaluation of a hand-washing promotion program in Chinese primary schools, rates of diarrhoea were too low in both intervention and control groups to identify attributable differences in prevalence [ 35]. Some studies indicated that basic interventions that include hygiene promotion, water treatment, and behaviour change did not reduce rates of diarrhoeal disease [ 11, 15]. In a multi-country study, Dujister et al. [ 20] found that the STH prevalence at baseline and at follow-up did not significantly differ between intervention schools (that provided deworming and improved handwashing) and control schools. And a study by Greene et al. [ 25] conducted in schools in western Kenya found that hygiene promotion and water treatment did not reduce risk of Escherichia coli presence on pupils' hands; further, the addition of new latrines to intervention schools significantly increased E. coli presence among girls (RR = 2.63, 95% CI 1.29-5.34) which they attributed to an absence of sufficient hygiene behaviour change, and lack of soap, water, and anal cleansing materials. It is important to note, however, that presence of E. coli on hands is a variable that is difficult to interpret in terms of disease risk and outcomes.

Context is important. For example, Freeman et al. [ 11] found that local water availability affected the impact of school-based WASH interventions on diarrhoea rates among pupils. Pupils attending 'water-scarce' schools (in which there was no dry-season water source within 1km) that received WASH intervention (including water-supply improvement, hygiene promotion and water treatment, and sanitation improvements) reported a reduction in diarrhoea incidence and days of illness; they reported a 56% difference in the risk of diarrhoea for pupils attending intervention vs. control schools in water-scarce sites (adjusted risk ratio (aRR) 0.34, 95% CI 0.17-0.64). No statistically significant effect was detected for any intervention in 'water-available schools', nor for 'water-scarce' schools that received only hygiene promotion and water treatment. Similarly, Garn et al. [ 44] found that in water-scarce schools in Kenya, there was reduced prevalence of diarrhea among pupils attending schools that adhered to two or three intervention components (prevalence ratio 0.28, 95% CI 0.10-0.75), compared with schools that adhered to zero components or one. It was not clear why results were different in water-scarce versus water-available schools, but it is possible that WASH interventions in water-scarce schools were more comprehensive.

There is widespread recognition that WASH infrastructure and resources are important foundations for hygiene behaviour change and reduced risk of WASH-related diseases. There is evidence, however, that latrine construction, without other supporting water and hygiene-related interventions, is not effective at reducing diarrhoeal disease [11, 20). Possible explanations are that without broader hygiene promotion and latrine maintenance efforts, construction of latrines alone may not result in their use or (conversely) latrines may increase exposure to faecal pathogens if they are poorly maintained, used incorrectly, or if hygiene resources are not available during and after use [ 11, 36]. The health benefits of improved WASH infrastructure and resources in schools may depend on consistent availability of soap and water for handwashing and on conditions of the latrines, not only pupil to latrine ratios [ 26].

3.3. Improved WASH Knowledge, Attitudes and Hygiene Behaviours

Thirteen studies measured WASH knowledge, attitudes and hygiene behaviours among students (see ); all found evidence of improved knowledge, attitudes and behaviours associated with WinS program. Dreibelbis et al. [ 29] report findings of an intervention that aimed to improve hand-washing after toilet use among students in two primary schools in rural Bangladesh. Dedicated locations for hand-washing were constructed in both schools. Two nudges were implemented: first, connecting latrines to hand-washing stations via brightly painted paved pathways; second, painting footprints on pathways guiding students to the handwashing stations and handprints on stations. Soap was provided and schools were asked to make soap available and refill water storage containers each day. At baseline, hand-washing with soap (HWWS) was low (4%); this increased to 68% the day after nudges were completed and 74% at both 2 weeks and 6 weeks post intervention. The high rates of observed handwashing post-intervention suggest that nudges can have sustained effects on hygiene behaviours. A related cluster-randomized trial in schools Bangladesh [ 30] demonstrated comparable increases in rates of handwashing with soap five months after intervention both for a nudge intervention (paved path with painted shoe-prints and arrows connecting latrines to the handwashing facility, painted handwashing station with handprints and a dedicated location for soap) and high intensity hygiene education initiatives. La Con et al. [ 31] found that installation of water and handwashing stations in schools in rural Kenya, coupled with WASH education, enabled student handwashing with stations located closer to latrines (<10 m) used much more frequently. One randomized cluster trial in rural Kenya [ 17] examined the impact of provision of regular soap and latrine cleaning materials and hygiene education; pupil hand-washing rates following toileting were observed to be 32-38% in intervention schools compared to 2% of students in control schools. Another randomized cluster trial in urban Nairobi, Kenya, examined the impact of teacher hygiene training and provision of regular alcohol-based hand sanitizer or liquid soap; pupil hand-washing rates following toileting were observed to be 82% at schools with sanitizer, 38% at schools with soap, and 37% at control schools [ 16].

3.4. Reduced Disease Burden and Improved Hygiene Practices in Households and Communities

In addition to limiting pathogen transmission in the public domain-such as at schools-school-level WASH interventions may also reduce community disease burden and improve hygiene knowledge. One study in Kenya found that in water-scarce areas, school-based WASH interventions that included improvement in water supply reduced diarrhoea among school students' siblings under the age of five who were not attending school [ 33]. The authors suggest this could be due to diffusion of improved hygiene practices and behaviours in both home environments and community, or interruption of pathogen transmission in school contexts thereby reducing exposure and transmission in domestic environments. Another study in Kenya documented transfer of knowledge from school students to their parents, identifying increased parental awareness and household use of water treatment with flocculent disinfectant following student hygiene education and provision of water treatment products to students; improved household water treatment practices were sustained over one year [ 32]. A study of a school-based WASH intervention in Kenya documented the transfer of knowledge about point-of-use water treatment practices and increased utilisation of WaterGuard in student's households as indicated by having chlorine residuals in stored water; parents also reported improved hand-washing and 38% of parents demonstrated correct hand-washing technique [ 14]. However, based on their study in Burkina Faso, Erismann et al. [ 10] warn that although children can promote health messages to family members, effective behaviour changes among family members is more difficult to achieve due to the challenge of changing practices and the broader constraints that limit improved behaviours (e.g., water scarcity).

3.5. Improved Student Enrolment and Attendance

In this review, twelve studies in low-income countries were identified that examined the impact of school-based WASH programs on student absence and enrolment. Improved school WASH conditions may reduce student absence by providing services (including, importantly, for girls who are menstruating) and by reducing illness transmission [ 45]. There is some evidence that improved hand-washing with soap at school can reduce illness in school-aged children thereby reducing absence from school [ 11, 14, 15, 18, 21, 35, 41].

Interventions that deliver hand-washing promotion and point-of-use water treatment have reported reductions in student absence of between 21% [ 32] and 61% [ 38] with one study specifically identifying reduced absence among girls (i.e., 58% reduction in the odds of absence for girls) [ 21]. A school-based water and hygiene intervention in public primary schools in Kenya found a decrease in student absence of 35% relative to baseline as compared to a 5% increase in neighbouring schools [ 14]. Talaat et al. [ 41] identified a 21% reduction in school absence from all illnesses (e.g., diarrhea, conjunctivitis, influenza) as a result of an intensive hand-washing campaign in Egypt; absences caused by influenza-like illness, diarrhea, conjunctivitis, and laboratory-confirmed influenza were reduced by 40%, 33%, 67%, and 50%, respectively. A small pilot study in Ghana entailed provision of sanitary pads and puberty education to adolescent girls in both intervention and control schools, with the intervention found to significantly improve attendance [ 39]. Evaluation of a comprehensive WASH intervention in schools in Bangladesh-using a non-experimental survey design-reported a 9-12% reduction in school absence among girls (varying between schools) [ 42]. A trial of school-based WASH interventions in Kenya found that cleanliness of latrines was strongly correlated with recent student absence [ 37]. And a study of hand-washing intervention in Chinese primary schools found that the expanded intervention (standard government education plus hand-washing program, soap for sinks, and peer hygiene monitors) reported 42% fewer absence episodes and 54% fewer days of absence, and the standard intervention (handwashing program) reported 44% fewer absence episodes and 27% fewer days of absence [ 35].

Some intervention studies, however, found no evidence of impact on attendance. A study in the Chitwan region of Nepal [ 40] trialled the use of menstrual cups (a silicone cup used internally for menstrual flow management) with a small sample of schoolgirls. The study found the technology had no impact on school attendance or school test outcomes; the authors suggest this is because the technology assisted only with management of blood, and did not reduce cramps which were reported as the primary reason for non-attendance. However, the study had several limitations including self-reporting of menstrual cup usage, and lack of consideration of existing water and sanitation facilities in schools. And a trial in Kenya to assess the impact of a scalable, low-cost, school-level latrine cleaning intervention on pupil absence did not find a reduction in absenteeism; the authors hypothesised that the additional impact of cleaning may not have been sufficient to reduce absence beyond reductions attributable to the original WASH intervention [ 36].

3.6. Intervention Fidelity

Effectiveness of interventions is associated with the typically unmeasured and unreported 'output' and/or 'exposure' of intervention delivery including program fidelity and adherence. Three studies reported on intervention fidelity but did not draw conclusions as to its effect on measured outcomes. Chard and Freeman [ 9] report on a WASH intervention in Laotian primary schools and found inadequate school-level adherence to project outputs (e.g., soap provision, water availability, hygiene promotion activities); the differential impact of school-level intervention fidelity on measured hygiene behaviours (e.g., toilet use and daily hygiene activities) was not reported. Alexander et al. [ 43] assessed whether student and parental monitoring and additional funding for repairs and maintenance affected the fidelity and effectiveness of school-based WASH service provision in 70 schools in Western Kenya; no clear results emerged. Hetherington et al. [ 12] reported on an initiative in Tanzania that aimed to engage high-school students and the wider community in improving sanitation and hygiene. While they noted challenges of intervention adherence and fidelity-including timing of activities, communication between schools and local coordination, and inadequate supplies and allowances to support activities-the impact of these challenges on the primary outcome measures (i.e., hygiene knowledge, attitudes, behaviours) was not assessed. Garn et al. [ 44] provide rare evidence of the impact of intervention adherence and found that among water-scarce schools in Kenya improved adherence resulted in reduced prevalence of diarrhoea among pupils.

4. Discussion

Access to WASH facilities and hygiene behaviour change education in schools contribute to inclusion, dignity, and equity. From a human rights perspective, WASH in schools is considered essential. The Sustainable Development Goals (SDGs) implicitly highlight the need to expand WASH beyond household settings, in the effort to achieve universal and equitable access to safe and affordable drinking water, sanitation and hygiene for all. The SDGs explicitly refer to WASH in Schools in Target 4.a via the indicator of the "proportion of schools with access to: (e) basic drinking water; (f) single-sex basic sanitation; and (g) basic handwashing facilities" [ 46]. However, the aim is to not only provide adequate ratios, but to ensure positive outcomes across diverse measures including diarrhoeal disease and other WASH-related diseases, hygiene behaviour and school attendance.

There is biological plausibility supporting the health and educational benefits of providing WASH in schools, as well as rights-based arguments for WASH in Schools. The studies in this review indicate that school-based WASH interventions can protect against diarrhoea and other WASH-related illness such as soil-transmitted helminths and acute respiratory infections, increase WASH-related knowledge and practices, and improve educational outcomes including reduced absence.

Fourteen (78%) of the 18 publications that reported disease-related outcomes found reductions in diarrhoeal disease and other hygiene-related diseases, such as respiratory illness and soil-transmitted helminths, among students at intervention schools (c.f. [ 7, 18, 21, 28]). Of these publications reporting positive health outcomes, however, more than half also reported that there were no statistically significant reductions for some disease-related outcomes: e.g., intestinal parasitic infections prevalence, but not undernutrition, was found to decrease [ 10]. Four of the 18 publications reported no evidence of reduced risk for the primary disease-related outcome measures, including soil-transmitted helminths and E. coli on pupils' hands [ 17, 20, 25, 26].

All of the 13 publications that examined changes in WASH knowledge, attitudes and hygiene behaviours reported evidence of positive change among students in intervention schools including hand-washing with soap or sanitizer [ 8, 16, 29, 30, 31], improved knowledge of WASH-related diseases, and improved hygiene habits [ 7, 13].

Six studied examined whether WASH interventions in schools led to reductions in the family and community burden of WASH-related diseases and improved WASH knowledge at the family and community level. They provide very limited evidence of improvements in WASH-related knowledge and behavior and reduced WASH-related disease among family [ 14, 32, 33]. Further research is required to understand whether and how school-based WASH interventions can improve hygiene habits and disease-related outcomes among wider family and community members [ 29].

Demographic factors are key predictors of student absence from school, including gender and socio-economic status [ 37]. Nonetheless, WASH-related illnesses have been estimated to result in hundreds of millions of days of school absence [ 47]. Twelve publications examined the impact of school-based WASH interventions on student absence in low-income countries and the findings were mixed. There is some evidence that improved hand-washing with soap at school, provision of sanitary pads, maintained and clean latrines can reduce absence in school-aged children (c.f. [ 11, 18, 35, 37, 42]), but a few studies found that school-based WASH interventions had no impact on student attendance [ 36, 40].

Importantly, intervention effectiveness is affected by intervention delivery, including program fidelity and adherence. Freeman et al. [ 11] warn that suboptimal intervention fidelity often means that researchers evaluate the effectiveness of interventions in real-world settings, not ideal 'best practice' for WASH environments. Yet, while various publications mention the challenges of fidelity and adherence in school-based WASH interventions, their impact on outcomes is rarely assessed; only one study in schools in Kenya specifically demonstrated that improved intervention adherence resulted in reduced prevalence of diarrhoea among pupils [ 44]. Studies such as these highlight that ensuring consistent and effective delivery of WASH interventions in low-resources contexts, including school-based interventions, remains a challenge.

So, there is no universal blueprint and effects are not consistent between studies as both context and intervention type matter. For example, the effectiveness of an intervention in reducing diarrhoeal disease may be based on background rates of disease, pathogen-pathways in specific environments, student populations, baseline WASH conditions such as water availability, and broader social, political and economic contexts [ 11, 44]. Several publications emphasise that combined interventions that include multiple components-for example, latrine construction, hygiene promotion, latrine maintenance, and sustained provision of resources such as soap and water for handwashing-are more effective at reducing WASH-related diseases than single interventions such as construction of latrines [ 11, 21, 36].

Evaluative research of WASH in Schools encounters challenges which influence results and their interpretations, including: restrictions in randomisation, the potential of crossover effects, and circumstances beyond the researchers' control such as the interference of other health programmes. The definition of illness outcomes such as "diarrhea" are not uniform across studies which makes inter-study comparison difficult. And, importantly, evaluations of WASH interventions in low-resource settings often measure outcomes-such as diarrheal disease-via self-report, an approach prone to recall and social desirability biases, subjective interpretations of the definition of "diarrhea", and imprecise measurements of incidence [ 9]. It is notable that of the 18 studies in this review that report disease-related outcomes, ten (56%) included objective rather than self-reported measures of disease and infection: for example, fecal samples were examined for soil-transmitted helminths, intestinal protozoa and other parasites [ 7, 8, 10, 11, 20, 22, 24, 26], blood samples were collected to measure blood hemoglobin concentration [ 26], and hand-rinse samples were analysed for E. coli [ 17, 25].

The theory of change embedded in project design also influences the nature of an intervention and its delivery. In their evaluation of Project SHINE (Sanitation and Hygiene INnovation in Education) in Tanzania, for example, Hetherington et al. [ 12] highlighted the value of strategies that enable communities to develop locally sustainable approaches to improving their health, in contrast to other models (e.g., Community Led Total Sanitation) which incorporate shaming and disgust techniques to promote behaviour change. Theories of change must be considered to fully understand effectiveness, or lack thereof, rather than reducing interventions to processual elements of exposure and outcome.

Notably, several studies have examined the onset and management of menses in low-income countries, with a specific focus on the challenges of menstrual hygiene management (MHM) in school environments (e.g., negative attitudes, limited health and sexuality information, inadequate facilities and privacy) (c.f. [ 48, 49, 50]). However, these studies are qualitative and/or descriptive; very few intervention studies include a focus on menstrual hygiene management in schools in low-income countries [ 39, 40, 43].

This review contributes to understanding of the impact of school-based WASH interventions beyond the two existing reviews of school-based WASH by Jasper et al. [ 2] and Joshi and Amadi [ 4]. First, these two existing reviews have no restrictions on study location and more than two thirds of the 41 articles in the review by Jasper et al. [ 2] report findings of research conducted in high-income countries (e.g., United Kingdom, United States, Germany) and almost one third of the 15 articles in the review by Joshi and Amadi [ 4] were conducted in developed countries; this review has an explicit focus on low-income countries where there is the greatest need for improved access to safe drinking water, improved sanitation, handwashing facilities and hygiene education [ 47]. Second, these reviews necessarily include only publications available up to 2012: the Jasper et al. review [ 2] had no time restriction on the date of publication and the search was conducted in 2010 and updated in 2012; the Joshi and Amadi [ 4] review was restricted to studies published between 2009 and 2012 and the search was conducted in 2013. In this review, however, twenty-five of the 38 studies included were published after 2012. The contribution of this review, then, is its explicit focus on low-income countries and its inclusion of the substantial body of relevant research published in the last several years.

5. Conclusions

It is important to better understand disease-related and educational outcomes of school-based WASH interventions. This can help governments and donors allocate resources to school-based WASH interventions and enable agencies to design and implement effective interventions [ 11]. Intervention studies of WASH in schools in low-income settings are both expensive and challenging. There is, arguably, no need for additional large-scale epidemiological studies on the impact of WinS on diarrhoea among students as numerous studies have found evidence of positive outcomes related to diarrhoeal disease [ 11]. There is, however, still a need to better understand the differential impacts of different types of WinS programmes for broader health and educational outcomes, the extent to which students operate as change agents in wider communities, the role of independent variables including gender and socio-economic status, and the effect of targeted initiatives on menstrual hygiene management and girls' school attendance. Further, there is value in conducting process evaluations that identify opportunities and challenges within program implementation, including theories of change and intervention fidelity. Political will and financing and effective delivery of interventions will be required to ensure universal access to WASH in Schools including in low-income countries.

Acknowledgments

The author would like to thank the librarian who assisted with the search strategy associated with this publication, David Honeybone at The University of Melbourne.

Funding

This research received no external funding.

Conflicts of Interest

The author declares no conflict of interest.

References

# data[].attributes.attachment_link.title
Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact

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Many schools in low-income countries have inadequate access to water facilities, sanitation and hygiene promotion. A systematic review of literature was carried out that aimed to identify and analyse the impact of water, sanitation and hygiene interventions (WASH) in schools in low-income countries.

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The government requires public schools to have free water that is clean and safe for the children. Most schools follow a variety of strategies to ensure that the water they provide for the students promotes healthy well-being because the benefits of water are immense in a child’s growth and health. Without it, the health could be negatively affected which directly influences their school performance.

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Providing access to drinking water gives students a healthy alternative to sugar-sweetened beverages. It helps to increase students' overall water consumption, maintain hydration, and reduce energy intake if substituted for sugar-sweetened beverages. ¹⁻³ Adequate hydration also may improve cognitive function in children and adolescents. ⁴⁻⁸ Drinking water, if fluoridated, also plays a role in preventing dental caries (cavities).

The Healthy, Hunger-Free Kids Act of 2010 requires schools participating in the National School Lunch Program (NSLP) to make free water available to students during meal times where they are served. The standards also require schools in the School Breakfast Program (SBP) to make drinking water available when breakfast is served in the cafeteria.

In addition to the requirements, schools can use a variety of strategies to:

Ensure that water fountains are clean and properly maintained.

Provide access to water fountains, dispensers, and hydration stations throughout the school.

Allow students to have water bottles in class or to go to the water fountain if they need to drink water.

US Environmental Protection Agency (EPA) standards and regulations assure that public water supply is clean and safe before it leaves the water utility. However, lead plumbing parts (pipes, fittings, and fixtures) can contaminate water after it leaves the water main. Schools can test the water quality and have a plan in case there is contamination. In cases when tap water may not be safe to drink, schools can provide drinking water to students in other ways until the contamination can be fixed. This includes installing filtration systems or purchasing drinking water.

These short video training modules guide schools on steps to take to help students drink more water during the day. School staff will learn what can be done to ensure water is available, safe, and promoted as an ideal beverage choice.

The sections in the toolkit are available below for quick access.

1. Kaushik A, Mullee MA, Bryant TN, Hill CM. A study of the association between children's access to drinking water in primary schools and their fluid intake: can water be 'cool' in school? Child: Care, Health & Development. 2007;33:409-15.

2. Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M. Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial. Pediatrics. 2009;123:e661-e667.

3. Wang Y C, Ludwig DS, Sonneville K, Gortmaker SL. Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents. Archieves of Pediatric & Adolescent Medicine. 2009;163(4):336-343.

4. Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration, and health. Nutrition Reviews. 2010;68(8):439-458.

5. Kempton MJ, Ettinger U, Foster R, Williams SCR, Calvert GA, Hampshire A, et al. Dehydration affects brain structure and function in healthy adolescents. Human Brain Mapping. 2011;32:71-79.

6. Edmonds CJ, Jeffes B. Does having a drink help you think? 6-7 year-old children show improvements in cognitive performance from baseline to test after having a drink of water. Appetite. 2009;53:469-472.

7. Edmonds CJ, Burford D. Should children drink more water? The effects of drinking water on cognition in children. Appetite. 2009;52:776-779.

8. Benton D, Burgess N. The effect of the consumption of water on the memory and attention of children. Appetite. 2009;53:143-146.

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centers for disease control and prevention

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The Healthy, Hunger-Free Kids Act of 2010 requires schools participating in the National School Lunch Program (NSLP) to make free water available to students during meal times where they are served. The standards also require schools in the School Breakfast Program (SBP) to make drinking water available when breakfast is served in the cafeteria.

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This is a 3 minute long video, that can be shown to a group of third grader. Teacher can do a synthesis strategy to show how they feel  about the visual. The students will have to draw up connections regarding how they feel and think.

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Follow the Water | Plum Landing Videos | PBS KIDS

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How does water get from a driveway to a river? Ella and her dad track melted snow from their backyard into the world.

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These dark, narrow, 100 meter-long streaks (called recurring slope lineae) are flowing downhill on Mars, and are inferred to have been formed by contemporary flowing water. Recently, planetary scientists detected hydrated salts on these slopes at Hale crater, corroborating their original hypothesis that the streaks are indeed formed by liquid water. The blue color seen upslope of the dark streaks are thought not to be related to their formation, but instead are from the presence of the mineral pyroxene.

Credit: NASA/JPL/University of Arizona

Water. It's found everywhere on Earth, from the polar ice caps to steamy geysers. And wherever water flows on this planet, you can be sure to find life.

"When we find water here on Earth - whether it be ice-covered lakes, whether it be deep-sea hydrothermal vents, whether it be arid deserts - if there's any water, we've found microbes that have found a way to make a living there," said Brian Glazer, an oceanographer at the University of Hawaii at Manoa, who has studied astrobiology.

That's why NASA's motto in the hunt for extraterrestrial life has been "follow the water."

Yesterday (Sept. 28), NASA scientists announced they'd found it on Mars: Dark streaks that scientists have spotted seasonally for more than a decade in images of the Red Planet are evidence of flowing water, new research suggests. While the briny flows may be too full of chlorine-based salts to support life, they do raise the odds that Mars could have life right now, the researchers said. [ In Photos: Is Water Flowing on Mars?]

But just why is water such a crucial molecule for life? And could there be other ingredients that also provide the perfect recipe for life on other planets?

It turns out that several chemical properties of water make it indispensable for living creatures. Not only can water dissolve nearly anything, but it is also one of only a few materials that can exist as solid, liquid and gas within a relatively narrow range of temperatures.

Flowing life

At heart, all life on Earth uses a membrane that separates the organism from its environment. To stay alive, the organism takes in important materials for making energy, while shuttling out toxic substances such as waste products.

In this regard, water is essential simply because it's a liquid at Earth-like temperatures. Because it flows, water provides an efficient way to transfer substances from a cell to the cell's environment. By contrast, deriving energy from a solid is a much tougher prospect (though there are microbes that eat rock), Glazer said.

But the other part of the equation - that water can carry things into and out of the cell - has to do with water's unique chemical configuration.

The humble water molecule is made up of two hydrogen atoms bonded to an oxygen atom.

"The way they're bonded together makes water this wonderful universal solvent," meaning that almost every substance can dissolve in water, Glazer told Live Science.

That's because the molecule has polarity, meaning the hydrogen atoms tend to bunch on one side of the molecule, creating a positive region, while the oxygen end has a negative charge. The positive hydrogen end tends to attract negative ions (or atoms with an extra electron in the outer shell), while the negative region lures in positive ions (which have had one of their electrons stripped off).

Water, with its amazing dissolving properties, is the perfect medium for transmitting substances, such as phosphates or calcium ions, into and out of a cell.

Phases of water

Another feature of water is that it can act as a solid, liquid and gas within the range of temperatures that occur on Earth. Other molecules that have been identified as good candidates for supporting life tend to be liquid at temperatures or pressures that would be inhospitable for most known life-forms, Glazer said. [ 5 Mars Myths and Misconceptions]

"Water really is at that sweet spot," Glazer said.

The fact that water can be in all three phases in a relatively tight range of pressures creates many opportunities for life to flourish, he added.

"All three [states of water] available on our planet creates this really neat variety of habitats and microclimates," Glazer said.

For instance, frozen ice can be found in glaciers that carve through mountains, whereas water vapor helps warm the atmosphere, Glazer said.

Watery cradle of life

Water may be more than a fluid to help facilitate life's essential processes - it may also have been the protective cradle that carried the building blocks of life to Earth, said Ralf Kaiser, a physical experimental chemist at the University of Hawaii at Manoa, who has research experience in astrochemistry.

One theory for how life on Earth emerged, called panspermia, posits that icy comets smashed into Earth, bearing tiny organic molecules that formed the precursors to life. But traveling through space is a harsh journey, with punishing levels of radiation that would normally degrade those delicate molecules, Kaiser said.

However, in its solid form, water could have provided a way to shield those molecules from radiation, Kasier speculated.

"One possibility is that because the building blocks are frozen within the water, it has this protective mantle around it that could be delivered," Kaiser told Live Science.

Accept some substitutes

Of course, while water is crucial to life on our home planet, there could be life-forms that don't conform to the Earthling playbook.

Scientists are also looking at other liquids that could play a similar role as universal solvent and transport medium. Some of the top contenders are ammonia and methane, said Chris McKay, an astrobiologist at the NASA Ames Research Center in Moffett Field, California. Ammonia, like water, is a polar molecule that is relatively abundant in the universe, but scientists haven't found any large bodies of ammonia anywhere in the solar system, McKay said.

Methane isn't polar, but it can dissolve many other substances. Unlike water, however, methane becomes liquid only at very cold temperatures - at a frigid minus 296 degrees Fahrenheit (minus 182 degrees Celsius).

"We know that there are large lakes of liquid methane and ethane on Titan," one of the moons of Saturn, McKay told Live Science in an email. "Thus there is keen interest is the question of whether life can use liquid methane/ethane."

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Water. It's found everywhere on Earth, from the polar ice caps to steamy geysers. And wherever water flows on this planet, you can be sure to find life.

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Water Pollution: Everything You Need to Know

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Our rivers, reservoirs, lakes, and seas are drowning in chemicals, waste, plastic, and other pollutants. Here’s why―and what you can do to help.