Hygiene system modeling for toileting in schools

Background: Hygienic toileting is associated with positive health outcomes; yet efforts to provide the necessary preconditions for this behavior, namely provision of anal cleansing materials, a well-maintained toilet facility, and handwashing, are often limited—especially in schools—by a complex set of determinants and upstream factors that hinder access to the materials and behavioral drivers required for effective practice. Systems thinking, and its associated tools, is one approach to understanding and developing interventions to address the complexity of an interconnected set of factors impacting hygiene program outcomes.

Methods: This study modeled the interconnected factors influencing preconditions for hygienic toileting in schools using expert-based participatory systems modeling. Two global hygiene meetings were utilized to recruit participants for hygiene systems modeling, and to compare results across two distinct groups of model participants. Participants identified and prioritized hygiene system factors, created systems models, and performed structural analyses using influence maps and causal loop diagrams to compare key leverage points driving hygienic toileting in schools.

Results: Participants prioritized nine factors. Three of the nine factors were found to be highly influential and to drive the core system dynamics across both groups of participants: WASH leadership, governance, and partnerships; resource mobilization; and human resource capacity.

Discussion: Our study identified leverage points for system strengthening to deliver the preconditions for hygienic toileting in schools. Systems thinking should precede system strengthening to ensure the efficient and effective use of resources and to enhance the sustainability of outcomes.