Sustaining an elementary school-based hygiene intervention in Bangladesh by forming ‘hygiene committees’: a pilot study

Schools gather many students in a specified site for a prolonged period. This provides an ideal setting for infectious disease transmission and outbreaks (Bartram et al. 2009; Stebbins et al. 2009; Xue et al. 2012), with opportunity for onward transmission to family members (UNICEF 2010). Previous studies have identified the high burden of a range of infectious diseases including diarrhea, respiratory, and helminth infections among school-aged children (Rabie & Curtis 2006; Waddington et al. 2009; United Nations Children's Fund and Regional Office for South Asia (UNICEF ROSA) 2012). In a systematic review focused on children in educational settings, illness was reported as a major cause of school absenteeism (Joshi & Amadi 2013). Student attendance can ultimately affect academic performance (Gottfried 2010).

School-based promotion of water, sanitation and hygiene (WASH) is an effective strategy to reduce disease burden in low- and middle-income countries, including Bangladesh (Ejemot et al. 2008; Catalina et al. 2009; Freeman et al. 2012; Thanh Xuan et al. 2013; Bowen et al. 2018; McMichael 2019). Previous studies have documented the outcome of water treatment, hygiene and sanitary practices on improving attendance, academic performance, and health of school-age children (Ejemot et al. 2008; Catalina et al. 2009; Freeman et al. 2012). Furthermore, school-based hygiene interventions markedly improve short-term outcomes, for instance, washing hands at critical times, drinking safe water, and using upper sleeve during coughing (Dreibelbis et al. 2016; Sultana et al. 2017; McMichael 2019; Yeasmin et al. 2019; Sultana et al. 2021). However, a recent systematic review on sustained adoption of WASH interventions identified that most articles focused on ‘initial WASH behavior adoption’ whereas only two studies addressed sustained adoption (Martin et al. 2018). Poor maintenance of sanitary toilets and unavailability of handwashing materials (e.g. soap) during post-intervention months or years were reported previously in school settings (Catalina et al. 2009; Mathew et al. 2009; Saboori et al. 2011). For instance, combining water storage for handwashing, point-of-use drinking water treatment, and hygiene education, a 1-year Safe Water System promotion program was piloted in 60 Kenyan elementary schools. In a sustainability evaluation, that is, 2.5 years after implementation, only one out of 55 pilot schools had handwashing soap near the handwashing containers and this school did not have drinking or handwashing water (Saboori et al. 2011). A study on the sustainability and impact of WASH interventions conducted among 300 Indian upper elementary schools revealed that more than 94% of students from intervention schools washed their hands before eating with water only, as soap near handwashing stations was rarely available (Mathew et al. 2009).

Schools play an important role in promoting health literacy among students (St Leger 2001). There are limited data on strategies to institutionalize hygiene interventions in schools. In Bangladeshi schools, a water treatment, handwashing, and coughing etiquette intervention was successful in changing these behaviors, up to 14 months after a 1-month intervention (Sultana et al. 2017; Yeasmin et al. 2019; Sultana et al. 2021). In this paper, we described how forming a ‘hygiene committee’ within the school community helped to institutionalize this school-based hygiene intervention, its role in intervention implementation and sustainability beyond the implementation period.

The findings presented in this paper were generated from a multi-component project, which was conducted between May 2011 and September 2013 among elementary school students in urban and rural Bangladesh to generate evidence on hardware designs and social and behavior change communication materials for an elementary school-based hygiene intervention in Bangladesh. This research purposively included four urban (located in Dhaka) and four rural (located in Mymensingh, in north-central Bangladesh) co-education elementary schools, to capture variability in socio-demographic, cultural and geographic profile; half were government schools and half were non-government schools. The physical environment of the selected schools has been described in a separate paper (Sultana et al. 2017). A summary of the research project phases is provided in Supplementary material, Figure S1. Formative research methods, data collection process and results have been reported in separate papers (Sultana et al. 2017; Yeasmin et al. 2019; Sultana et al. 2021). Overall, the hygiene intervention contributed to 100% adoption of safe drinking water (from observation of 141 students), as documented in the 1-month assessment (Yeasmin et al. 2019). During the 1-month pilot intervention period, field workers observed that 46% of students washed their hands with soap before eating (Sultana et al. 2021). We found handwashing with soap and water after toileting increased from 0.7% (2/269) to 82% (154/187) in the follow-up visit after the start of piloting. Since there is limited research on mechanisms for adopting, sustaining, and institutionalizing hygiene interventions in schools, we aimed to address this knowledge gap and describe this tipping point from adoption of hygiene behaviors to maintenance of intervention activities. We qualitatively explored the perception of students, school principals, and school management committees regarding the elements of ‘hygiene committee’ engagement in elementary schools in Bangladesh.

Based on findings from formative research, teachers, representatives from school management committee and parent–teachers association members and the research team participated in a one-day workshop to design an acceptable and feasible hygiene intervention in January 2012. The systematic intervention development process has been detailed elsewhere (Sultana et al. 2017; Yeasmin et al. 2019). The intervention included hardware for each school as follows: (1) Handwashing facilities: plastic buckets as handwashing stations and soapy water bottles with a pump dispenser, (2) 100-L water storage tank with a tap, and a liquid chlorine dispenser for ensuring safe drinking water, and (3) Materials (cleaning brush, aprons and footwear) for cleaning sanitary latrine (Table 1) (Yeasmin et al. 2019; Sultana et al. 2021). US$ 54.10 for each of three schools with inconsistent water supply and US$ 44.10 for one school with consistent water supply (total US$ 206.40) was expended for the pilot hygiene intervention for 6 months (Table 1).

During the intervention development workshop, most of the teachers, school management and parent–teacher association members recommended forming a hygiene committee, with the school principal as the lead, to institutionalize the hygiene intervention in schools and maintain the activities beyond the research period. According to workshop participants, engaging a hygiene committee was important to coordinate hardware maintenance, including collecting the necessary funds. A full description of the hygiene committee of 18 members (in each school) is available in Table 2.

We piloted the hygiene intervention in four schools (additional to those included in the formative study) in June 2012, by installing WASH hardware, training teachers to lead and conduct social and behavior change communication sessions and forming a hygiene committee. Four weeks after the pilot intervention commenced, fieldworkers conducted a qualitative assessment in July 2012 to explore perceptions, perceived benefits, motivations and barriers regarding appointing a hygiene committee for intervention hardware maintenance and cost recovery in schools. Qualitative assessment included 12 focus group discussions: four with Grade 4 students, four with Grade 5 students and four focus group discussions with teachers, school management committee and parent–teachers association members (Table 3). Participants were selected based on availability and willingness to participate in focus group discussions. However, we included seven students of grade III in one school. We took additional open-ended field notes during formal interviews and informal observations.

Fourteen months after the pilot intervention commenced, the research team revisited the four pilot schools in August 2013 to explore frequency of target intervention behaviors and functionality of the hygiene committee in hardware maintenance and cost recovery. Field staff conducted 12 focus group discussions with students, teachers, school management committee and parent–teachers association members to explore the functionality of the hygiene committee in hardware maintenance and persistency in cost recovery for intervention consumables (Table 3). They also interviewed two janitors, one from each urban school. Each focus group had eight to fourteen participants who were purposively sampled in accordance with the maximum variation sampling procedure in order to facilitate the understanding of the diversified issues related to the hygiene committee activities.

Detailed approaches and findings have been described and presented previously (Sultana et al. 2017; Yeasmin et al. 2019; Sultana et al. 2021). Briefly, fieldworkers conducted spot checks of WASH facilities before and after intervention rollout to explore the improvement in the physical environment. They also conducted 4-h long structured observations at baseline, at 1 month and 14 months follow-up assessments to identify hygiene behavior change and habit adoption.

We used the Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH) adapted for school WASH interventions as a guide for data collection and analysis (Dreibelbis et al. 2013). We explored three major dimensions: (a) contextual (i.e. school policies, existing hygiene and sanitation facilities, interest in taking responsibilities, motivational factors, regular school timing), (b) psychosocial (i.e. leadership and ownership of school community, support and commitment of teachers and students, promoting targeted practices), and (c) technological (i.e. ease to maintain, low-cost facilities, demonstration of use) (Table 4). Detailed analysis using different factors of this model in this study has been described previously (Sultana et al. 2017). Briefly, the contextual dimension is the social and physical environment in which the WASH behaviors and technologies are implemented; a psychosocial or software dimension relates to the social and psychological factors that affect WASH practices; and finally, a technological or hardware dimension relates to the factors affecting adoption of WASH technologies. Table 4 represents the formative study findings in contextual dimension that we used to develop the intervention package, and the psychosocial and technological dimensions represent the behavior change communication strategies and WASH hardware-related findings after the intervention was implemented.

Experienced and well-trained researchers conducted focus group discussions and in-depth interviews in the native language, Bengali. From audio recordings, field researchers transcribed the qualitative data verbatim in Bengali. We cross-checked the transcripts with audio recordings to avoid discrepancy and misinterpretation. We drew from the IBM-WASH model, adapted for school WASH interventions, to develop an a priori codebook and completed thematic analysis as shown in Table 4. This framework distinguishes between factors affecting WASH behaviors along contextual, psychosocial and technological dimensions (Dreibelbis et al. 2013). We included new codes as they emerged. Notably, a priori codes based on both the IBM-WASH model and the emerging codes were used in a previous study (Rothstein et al. 2015). Before coding, we read the transcripts thrice to gain familiarity with them. Then we clustered and compared the coded data to identify patterns. We analyzed the qualitative data from in-depth interviews and focus group discussions separately for ensuring triangulation and drew inferences collectively from both data sources. We reported findings based on the ‘Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist’ (Supplementary material, Table S1) (Tong et al. 2007).

During piloting, the handwashing station maintenance responsibility (i.e. refilling water in buckets, preparing soapy water and emptying wastewater from the bucket) was assigned to student members of the hygiene committee under the teachers' supervision in both in urban and rural schools.

Actions to ensure access to safe drinking water (cleaning and storing water in a 100-L vessel, dosing chlorine, and ensuring a 30-min waiting time before drinking) were performed by students in rural schools and janitors in urban schools. As urban schoolteachers perceived the dosage of chlorine as a critical concern for water purification, they engaged the janitor. However, one janitor perceived this additional involvement as an extra burden in absence of financial incentives:

Janitors at urban schools and student members at rural schools were assigned to clean school latrines during the school week. The janitors mentioned that the latrine cleaning materials such as aprons, brushes and regular supply of disinfectant toilet cleaners made cleaning work easier. The hygiene committees' student members from four schools opined that three motivators encouraged them to clean latrines: weekly social and behavior change communication classes, interest to protect the school students from water and air borne diseases, and enthusiastic parents at home. Students engaged in maintenance activities and acted as role models for the younger students. Motivation from peers encouraged students to practice hygiene behaviors during school hours, as echoed in an interview with a teacher from a rural school:

The findings correspond to the School/School Principal/School Management Committee and interpersonal rows and technology dimension in the IBM-WASH framework (Table 4) (Dreibelbis et al. 2013).

The school community members (teachers, school management committee, and parent–teacher association) and students at all schools appreciated having a hygiene committee to encourage positive behavioral practices among students and to promote continued hygiene intervention activity at their schools.

Student hygiene committee members reminded fellow students to practice recommended hygiene behaviors including handwashing with soapy water at the three recommended times, drinking safe water, pouring water after toileting. They also advised on methods to prevent misuse of sanitation materials (e.g. wasting treated drinking water, playing with soapy water). Thus, engagement of students facilitated a sense of ownership through participation in a leadership role, maintenance support and positive attitudes.

The findings correspond to the interpersonal and individual rows and psychosocial dimension in the IBM-WASH framework (Table 4) (Dreibelbis et al. 2013).

The spot checks water revealed that the provision of hardware improved schools' physical environment favoring handwashing with soapy before eating, and after toileting and after cleaning toilet and safe drinking water practices (Sultana et al. 2017; Yeasmin et al. 2019; Sultana et al. 2021).

At baseline, among 63 observed students, 58 (92%) coughed/sneezed into open air, five (8%) covered coughs/sneezes with their hands, which were not subsequently washed with soap and water as they judged this infeasible. After 4 weeks, among 70 observed students, 27 (39%) coughed/sneezed into upper sleeves, 33 (47%) into open air, and 10 (12%) covered with hands. After 14 months, among 230 observed students, 13 (6%) used upper sleeves, 154 (67%) coughed/sneezed into open air, and 59 (26%) covered with hands (Sultana et al. 2017).

At baseline, of 300 before eating events, no one washed hands with soap, and 99.7% (299) did not wash hands at all as soap was unavailable. Out of 269 after toileting events, 0.7% (2) washed hands with soap, and 88% (237) did not wash hands. After 4 weeks of the intervention, 45% (87/195 before eating events), 83% (155/186 after toileting events), and 100% (15/15 after cleaning toilet events) washed both hands with soapy water as children found it accessible, low cost, and child friendly. After 14 months, 9.4% (55/586 before eating events) and 37% (172/465 after toileting events) washed both hands with soapy water for health benefits (Sultana et al. 2021).

During 1-month follow-up, among 141 drinking events observed, 141 students (100%) drank chlorinated water. In 93 or 66% of events, students used their own bottles, and in 43 (30%) of the events, they used common cups or hands washed before drinking. During the 14-month follow-up, we observed 732 drinking events. In 653 of 732 events (89%), students drank chlorinated water; in 78 events (11%), they consumed water from untreated drinking water sources. Among those who consumed chlorinated water, 20% (131/653) used their own bottles to drink water, 72% (467/653) used common cups, and 8% (55/653) used both hands to drink water (Yeasmin et al. 2019).

The research team motivated the school community (teachers, school management and parents–teachers association committee members) to develop a system for recovering maintenance and consumable product costs. The aim of encouraging fund raising was to explore the potential for schools to cover the maintenance and repair expenditures beyond the project implementation period.

Since the maintenance cost was considered low, all the teachers, school management and parents–teachers association committee members of the hygiene committee contributed small amounts and developed a fund which was utilized to cover full cost of cleaning materials i.e. liquid chlorine, detergent sachet, disinfectant toilet cleaner. In total US$ 0.25–1.25 was disbursed from this fund to purchase a detergent sachet for daily use or a 1-kilogram packet for longer use (∼6 months). All school hygiene committees agreed to set up a fund and bought one bottle of 2-L liquid chlorine costing US$6, which lasted for 6 months.

At the time of piloting, the project supplied a 1-L disinfectant toilet cleaner (US$1.75) in each school for maintenance of sanitary toilets, which lasted for 2 months. At the end of piloting, hygiene committee members agreed to continue the recurrent cost of cleaning materials, considering cost effectiveness and health benefits of students. The student members were not included in fund raising, as the policy of the Government of Bangladesh states that elementary schooling is free of cost.

The findings correspond to the School system/Structural, School/School Principal/School Management Committee and individual rows and technology dimension in the IBM-WASH framework (Table 4) (Dreibelbis et al. 2013).

During the 14th month follow-up assessment, the presence of a functioning hygiene committee differed between urban and rural schools. Continuation of treating drinking water with chlorine and maintenance of the handwashing stations with stored soapy water was confirmed in one urban school. In another urban school, there were transfers of teachers who had been committee members to other schools, death of a janitor, trained students were promoted to Grade 6, and the hygiene committee became less engaged. Some school management committee and parent–teacher association members became inactive. In the absence of school management committee members, janitors and trained students, maintenance and monitoring no longer occurred and intervention hardware went missing. The absence of briefing and instructions on hardware use and maintenance among new janitors was also noted.

A similar situation was noted by a female janitor at an urban school,

In rural schools, maintenance activities were mainly carried out by student members of hygiene committees and teachers and school management committee members covered the recurrent cost for hardware maintenance. Rural schoolteachers ensured the availability and functionality of intervention materials in the school compound and distributed overall maintenance responsibilities to student members and janitors. The rural students were motivated to carry out their responsibilities as they came to the school earlier to perform maintenance work and ensure equal participation of all members.

In urban schools, due to the disagreement among parents in engaging students for these tasks, the teachers assigned janitors. In absence of incentives, the janitors perceived intervention material maintenance as an additional burden and threatened the school principal saying, ‘If the principal does not increase my salary, I will leave my job.’As urban students were less engaged, they played with intervention hardware, making it difficult for janitors to retain and sustain it.

The findings correspond to the School system/Structural and interpersonal rows with technology dimension, and individual rows with both psychosocial and technology dimension in the IBM-WASH framework (Table 4) (Dreibelbis et al. 2013).

We observed that leadership and decisions made by the hygiene committee in three of the four schools (two rural and one urban) created a supportive environment to monitor hygiene intervention materials, maintain hygiene facility functionality and cover consumable recurrent costs. Nevertheless, lack of hygiene facility maintenance (i.e. missing soapy water bottle) in one urban school at the 14 months follow-up suggests some limitations of the hygiene committee over longer term: agreement, decision-making, and communication within committee and member roles, specifically among students, teachers and school management committee representatives. Our findings illustrate the motivation, accountability and a ‘sense of ownership’ among hygiene committee members from rural schools. In contrast there was less engagement of urban school hygiene committees evident in infrequent maintenance and monitoring, which impacted intervention sustainability.

Inadequate financial planning and unavailability of a recurrent fund for interventions to cover the cost of soap, other consumables, operation and maintenance, are major barriers to a sustainable and mainstreamed WASH intervention in schools (Mooijman & Water 2012). Financial assistance from the community or government proved to facilitate well-managed sanitation services in Bangladesh's elementary schools. Active, motivated and independent teachers, who were dedicatedly responsible for sanitation facilities, could reverse the negative outcome of limited or no government support (Chatterley et al. 2014). The Government of Bangladesh provides government elementary schools with a contingency fund (approximately US$ 9 per month per school) for photocopying and managerial work. Regardless of student number, the government provides a School-Level Improvement Plan fund (approximately US$ 240–370 per school) on a yearly basis which can be used according to school needs (Chatterley et al. 2014). Specific amounts drawn from these funds can be allocated to maintain hygiene and sanitation facilities in elementary schools. In this project, the capital cost for intervention technologies per school was US$ 28.5 (Table 1), and had been anticipated to last at least five years, and the hygiene consumables and cleaning supplements cost was US$ 26 for three schools with inconsistent water supply and US$ 16.10 for one school with consistent water supply for the 6-month hygiene intervention. This could possibly be covered under the annual School-Level Improvement Plan fund. A recent systematic review identified three major financing models to support WASH programs in schools or community settings: government and public financing, private and donor's financial assistance and service user fees (McGinnis et al. 2017). We recommend testing these financing models in Bangladeshi school WASH programs in the future.

Along with regular government support and school management committee involvement, including a local sanitation champion, an accountable teacher and a maintenance plan acted as motivators for ensuring well-managed sanitation in Bangladeshi elementary schools (Chatterley et al. 2014). However, a team of school management committee representatives and teachers need to plan for and manage potential teacher transfer (Chatterley et al. 2014). Engagement of diverse community stakeholders can influence community ownership, trust of target population and understanding of local vulnerabilities, which are crucial factors for intervention implementation success (Sandison 2018), or as stated in one study ‘Involvement can take the shape of school management committees, parent–teacher associations or committees specifically set up for WASH in Schools’ (Mooijman & Water 2012). In our study, parents and the school community involvement were specifically coupled with collecting funds for hygiene consumable cost recovery. Outside of schools, community engagement has also supported WASH intervention uptake in other contexts (Waterkeyn & Cairncross 2005; Sinharoy et al. 2017).

Our findings highlight the advantages of student engagement and fostering their leadership. Students have the ability to maintain an effective WASH intervention if they obtain clear education and guidance (Bresee et al. 2016). In our case, the teachers guided the students. This complements the experience of a school-based participatory education and social entrepreneurship model ‘Project SHINE’ (Sanitation & Hygiene Innovation in Education) in Tanzania where the SHINE club's student members replicated lessons from classroom learning to school and community members under guidance of teachers (Greene et al. 2012). Student members also hosted sanitation science fairs. Students can effectively disseminate hygiene information learnt in the classroom to their friend, family members, relatives and neighbors (Bresee et al. 2016; Hetherington et al. 2017). Additionally, they can explain to and teach one another (Rohrbeck et al. 2003; Greene et al. 2012).

In this study, hygiene committees played a role and made centralized decisions on cost recovery and shared maintenance responsibilities (i.e. drinking water treatment timing, monitoring) in a ‘controlled’ school environment, contrasting with individual decisions and behaviors in the community setting. In households, human and financial resource availability, engaging local leaders, affordability, and willingness to invest influenced the sustainability of household-water treatment and storage practices, as mapped by Ojomo et al. (2015). Low community interest in paying water-point users fee and repairing non-functional water system was observed in Sub-Saharan African countries (Foster 2013; Klug et al. 2017). In Bangladesh, a large scale 5-year (2007–2012) WASH program resulted in low health impacts and low uptake due to limited supervision, management and performance monitoring of hygiene promoters who were the frontline actors (Huda et al. 2012; Benjamin-Chung et al. 2017). In our case, the hygiene committee took the opportunity of schools' regulatory framework, internal accountability, and commitment to promote and sustain hygiene intervention.

The systematic analysis of our findings using the IBM-WASH model indicated that a number of contextual, psychosocial and technological factors are important to influence and sustain school-based hygiene interventions and habit adoption (Dreibelbis et al. 2013). School community's willingness and commitment to maintain and promote the intervention activities at contextual level; self-efficacy and leadership role to continue the activities beyond the research period at the psychosocial level; and consensus to raise funds and recurrent costs for WASH facilities at the technological dimension (Table 4) enhanced the institutionalization and potential for sustainability. In interventions that require maintenance and funds within the schools, formation of ‘hygiene committees’ could be the key to high feasibility and acceptability as schools can create a supportive context both the individual, community and societal level.

The study has some limitations. The research was conducted among only eight schools, so we may have missed potential insights, reflections and contextual factors such as differences in the regulatory environment and good will of schools, water scarcity, planning and construction of existing facilities, and engagement of the school community if a larger sample had been included. We observed that hygiene committee members from rural schools were more engaged and active than urban schools, which may or may not generalize to other schools. A second limitation is the possibility of recall and reporting bias (Baird & Özler 2012). Courtesy bias was likely whereby participants might have been supportive of the intervention and provided positive insights rather than difficulties. To minimize this, during unannounced visits, we conducted spot checks and structured observation for specific indicators (i.e. number of students washed hands at three recommended times after teacher's announcement, functionality and availability of intervention material, and cleanliness of latrine) to monitor intervention progress and published elsewhere (Sultana et al. 2017; Yeasmin et al. 2019; Sultana et al. 2021). We also drew inferences collectively from different categories of participants, to minimize the impact of potential biases. It was not possible to explore all concepts elaborately from all categories of respondents because of school timetable constraints. We collected data within mid-morning breaks and after school classes ended. During breaks, the students were in hurry to play with their friends and were distracted, therefore potentially provided limited feedback. Teachers were busy with other academic and administrative work, potentially providing fewer responses.

The most recent Bangladesh National Hygiene Survey indicated that per elementary school spent US$ 2.6 (BDT 205) monthly for bar or liquid soap, 39% of the students had improved, unlocked, accessible toilets that have soap and water available and per toilet was shared by 121 students, and 64% toilets appeared clean (Bangladesh Bureau of Statistics 2020). The 2022 Progress on drinking water, sanitation and hygiene in schools by UNICEF and WHO suggest that there was a 57% point gap in basic hygiene coverage between primary (85%) and secondary schools (28%) in Bangladesh (UNICEF and WHO 2022). This suggests the solutions identified in our 2011–2013 study have the potential for sustainability in Bangladeshi schools.

In this pilot study, the school-based hygiene committee played an active role in monitoring hardware and consumable products and covering the recurrent cost of maintenance, suggesting their role in ownership development and intervention sustainability. Community participation, local capacity building with human and organizational resources, leadership, accountability, and decision-making are ‘interrelated dimensions’ in WASH sector empowerment (Dery et al. 2020). Future research should include community involvement strategies (i.e. introducing ‘school hygiene management’ as an agenda of the school management authority meetings, developing a ‘hygiene plan’ for managing maintenance and monitor and review the hygiene intervention materials' functionality and using ‘school assembly speech’ delivered by teachers for hygiene behavior adoption among children). For ensuring intervention sustainability, integrating cost recovery and community engagement strategies in school WASH program can be pivotal to be potentially included in policy and implementation processes. However, strategies and determinants of long-term engagement of hygiene committee in school WASH program can be explored in future.

The 2020 Bangladesh Strategic Paper (DPHE, Bangladesh 2020) written in response to the WASH issues during and post COVID-19 outbreak situation planned establishing handwashing stations at primary and secondary schools with a monthly real-time monitoring system with US$ 1 million budget to encourage and ensure students' handwashing practices. The Government of Bangladesh and UNICEF worked closely to develop school reopening guidelines and installing handwashing facilities, however, systematic monitoring and reporting on water quality and handwashing practices remains a constraint (UNICEF 2022). The lessons learned from this study could benefit monitoring and sustainability of WASH interventions within the schools. The hygiene committee's role in leadership, accountability and centralized decision-making within the school environment fostered student support, funding assistance and institutionalization in the present study, although teacher transfer, student up gradation and minimally engaged hygiene committee members potentially limited hygiene intervention sustainability in urban schools. Sustaining hygiene interventions can potentially reduce infectious disease transmission and outbreaks among students within school settings. The current study informs efforts to make a difference in the current school WASH landscape in Bangladesh; hygiene committee can monitor schools' existing WASH infrastructure. Additionally, the potential approach to be explored may include developing effective partnerships with local partners under corporate social responsibility (CSR) for continuous and sustained supply of intervention materials according to need. The government can also incorporate research evidence on hygiene intervention sustainability, specifically cost-recovery strategies in practice and policy decisions as a part of promoting evidence-informed decision-making. This intervention could be complementary to government investments in capital improvements in school wash infrastructure.

icddr,b acknowledges with gratitude the commitment of USAID to its research efforts. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. The authors express their gratitude to the study participants, the dedicated field team, and the school communities.

F.S. led the overall study, collected, and analyzed the data, implemented the intervention, and drafted the full report. S.M.K. drafted the manuscript with F.S., P.J.W., S.P.L., and L.U. conceptualized the study design, and guided the intervention and study implementation. S.P.L. contributed to the fund raising. L.U. guided the manuscript writing and all the authors reviewed the manuscript.

The study was approved by the icddr,b Ethical Review Committee. We sought permission from the Government of Bangladesh Divisional Primary Education Office, Dhaka, Bangladesh to work in specific schools in Dhaka and Mymensingh districts for research purpose. Teachers provided written consent and students assented to participate before we started interviews and focus group discussions with them. Before starting interviews and focus group discussions, we explained study objectives, activities, anonymity, and confidentiality to the participants and assured them that they could withdraw at any time. Our study involved no notable physical or psychological harm to the participants.

This study was supported by United States Agency for International Development (USAID).

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.