Water, sanitation and hygiene practices in early childhood development (ECD) centres in low socio-economic areas in Nelson Mandela Bay, South Africa

Water, sanitation and hygiene (WASH) are vital indicators to healthy living and safe environments for child development. The aim of the study was to determine WASH status and practices in ECD centres located in low socio-economic areas of Nelson Mandela Bay during 2017. This cross-sectional study elicited responses from 46 ECD centres which had a total of 3,254 children and 172 caregivers. A structured questionnaire and visual observation were used. Using core WASH in schools’ indicators (WinS) showed that despite improved water sources being available in 91% of the facilities, WinS for hygiene was poor. The study observed that 57% of the respondents had improved toilets accommodating both genders. In 29% of ECD centres, 6–10 children make use of a ‘pottie’ while in 9% of the cases, more than 20 children make use of one ‘pottie’. The use of the bucket system was noted in 22% of the ECD centres. In 79% of the ECD centres, children wash their hands in a communal plastic bowl. Only 11% of the study population washed hands hygienically under a running tap or tippy tap. WASH conditions in the ECD centres in the study area require urgent attention and further investigation for practical solutions. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/). doi: 10.2166/washdev.2019.130 om https://iwaponline.com/washdev/article-pdf/9/1/164/613277/washdev0090164.pdf 2020 Paula Melariri (corresponding author) Chwayita Mtembu Department of Environmental Health, Nelson Mandela University, P.O. Box 77000, Port Elizabeth 6031, South Africa E-mail: paulaezinne.melariri@mandela.ac.za Liana Steenkamp HIV&AIDS Research Unit, Nelson Mandela University, P.O. Box 77000, Port Elizabeth 6031, South Africa Margaret Williams Department of Nursing Science, Nelson Mandela University, P.O. Box 77000, Port Elizabeth 6031, South Africa Jessica Ronaasen Department of Social Welfare, NMU, P.O. Box 77000, Port Elizabeth 6031, South Africa Ilse Truter Drug Utilization Research Unit (DURU), Department of Pharmacy, Nelson Mandela University, P.O. Box 77000, Port Elizabeth 6031, South Africa This article has been made Open Access thanks to the generous support of a global network of libraries as part of the Knowledge Unlatched Select initiative.

INTRODUCTION especially in relation to childhood stunting (Cumming & Cairncross ). Accordingly, the provision of good quality water sources, sanitation and adequate hygiene practices are essential for the survival and development of children (Darvesh et al. ). Recently, improvements in WASH practices, attributable to robust interpersonal communication from a community health promoter, have been linked to improved child development in pre-school children (Tofail et al. ), which secures optimal school performance and better quality future outcomes.
In 2015 an estimated 5.2 billion people used a safely managed readily available drinking water service (UNICEF & WHO ). Conversely, the 844 million people who do not have access to sound water supplies (UNICEF & WHO ), have to make use of potentially unsafe drinking water sources such as unprotected wells, springs and surface water. In addition, 2.3 billion people globally do not have access to basic sanitation services.
Sub-Saharan Africa ranks at a low level regarding the improvement of drinking water sources and sanitation (Roche et al. ), and is eight times higher than other regions of the world in terms of providing satisfactory drinking water, which is due to a general lack of provision regarding maintenance and upgrading of sources (Grebmer et al. ). In 1996, approximately 21 million people in South Africa lacked access to adequate sanitation (Phaswana-Mafuya & Shukla ), despite attempts at improvement (Hoossein et al. ). There are definite problems regarding the sustainability of improving sanitation.
In 2016, there were approximately 1.26 million residents in Nelson Mandela Bay (NMB), 92.5% of whom had access to formal housing and 77.8% with piped water in their homes. Only 2% of households lacked piped water to yard level (one functional tap for the household) (ECSECC ). In 2016, 26,500 households in NMB had no formal refuse removal while 28,600 households experienced sporadic refuse removal (ECSECC ). Because of the increasing number of children in NMB who attend ECD facilities, it is essential to monitor WASH practices beyond the household level in order to achieve the Sustainable Development Goals (SDG), particularly SDG 6 (WHO/ UNICEF ). Thus, it is essential to monitor WASH in schools, particularly those accommodating children under five years of age.
Early childhood development is a priority area for stakeholders where intervention is required in order to provide equitable access to education and child services and to ensure the right to education. Currently, the Department of Social Development is responsible for ensuring quality ECD services and for supporting the registration, organization and management of these partial care facilities. ECD centres in South Africa are either school, community or home-based and only 12% of ECD practitioners are in possession of a recognized qualification (Atmore ). There are a total of 23,482 ECDs in South Africa with 1,030,473 children enrolled in the centres. Forty-nine per cent are in urban areas and 40% located in rural areas (Atmore ).
Flushing toilets and piped water are available in 53% of ECD facilities while 8% do not have flush toilets and piped water. The adverse effect of social and economic inequalities experienced by a majority of young children in South Africa have been described (Atmore ). is therefore vital to the well-being and educational outcomes of these school children (Jordanova et al. ). In the current study, a baseline evaluation of WASH practices at ECD centres in the study area was carried out to determine current practices. This was done in order to investigate the need for possible WASH intervention strategies to ensure alignment with the global strategy. The baseline study is pivotal in anchoring the implementation and development of future programmes. Findings from this study will facilitate targeting specific WASH concerns related to ECD centres in the study area.

MATERIALS AND METHODS
The study, which commenced in 2017, aimed to determine the WASH practices in ECD centres located in low socioeconomic areas of NMB. The study population comprised purposively selected ECD centres in NMB (n ¼ 46), all of which were associated with an ECD training centre, and all consented to participate in the study. All chosen ECD centres worked with children of 0-6 years of age.
A structured questionnaire developed for this cross-sectional study was used to gain responses regarding access to water, building type and composition plus sanitation and hygiene practices in the 46 ECD centres. Permission was obtained from the principal of each ECD centre prior to study commencement. A pre-tested questionnaire was administered to respondents (caregivers and principals in ECD centres) who consented to participate in the study.
The questionnaire was pre-tested to ascertain participants understanding of the research tool. The pre-test identified and revised questions that were ambiguous prior to the actual study. The content of the questionnaire was in line with the primary and specific objectives of the study and To determine the WASH conditions in the study area, the study evaluated ECD centres based on core WinS indicators adapted from UNICEF standards. The core indicators evaluated in the study area, based on the core WinS indicators adapted from UNICEF standards (WHO/ UNICEF ) were 'basic' drinking water, sanitation and handwashing. In this study an 'improved' drinking water source is one that is adequately protected from external contamination with faeces or disease vectors. According to the literature, optimal or so-called improved water sources for school settings include: 'piped, protected well/spring (including boreholes/tubewells, protected dug wells and protected springs), rainwater catchment, and packaged bottled water'. Not optimal or 'unimproved' sources include: 'unprotected well/spring, tanker-trucks, and surface water (e.g., lake, river, stream, pond, canals, irrigation ditches) or any other source where water is not protected from the outside environment' (WHO/UNICEF ). Descriptive statistics such as frequency tables and pie charts were utilized to present the data summary.

RESULTS AND DISCUSSION
Information on the composition of the ECD centres is provided in Table 1. There were 2,435 children enrolled in the 46 ECD centres with 172 caregivers. The ages of the children showed that approximately 72% of the children were five years or younger. The building type and composition of the facilities varied: 52% are centres built with permanent bricks, 30% were in a separate house while 26% were part of the caregivers' house (Table 1). Although the Department of Social Development (DSD) provides a subsidy in the form of financial support for registered ECD centres, most centres utilized in this study were not registered. The reason for this is that ECD principals, particularly in low socio-economic areas, were generally unable to register their centres because they do not meet infrastructural standards such as an adequate number of windows in the classrooms, or the building type and structure were substandard. Therefore, most of the ECDs in this study were unable to access financial support from DSD. Without access to governmental funding these centres cannot make the necessary structural improvements or repairs and are thus frozen in the unregis-  with which to optimally maintain adequate hygiene, their ability to maintain high WASH standards will be compromised. This is evident in the ECD centres which took part in this study where space availability is inadequate relative  (Table 2). Thirty-two (70%) used flush toilets while 9 (20%) and 28 (61%) used bucket and potties, respectively. Only 31 (67%) of the centres cleaned the potties after every use, and at 29 (63%) of the centres between one and five children shared one pottie. In 13 (29%) of the centres, 6-10 children shared a pottie, while in four (9%) of the centres 20 children shared one pottie, a concern. Similarly, 11-20 children and >30 children in 8 (18%) and 12 (28%) of the ECD centres, respectively, shared a wash basin while washing hands. According to the WinS indicator for sanitation in the study area, based on core WASH in schools' (WinS) indicators adapted from UNICEF standards (WHO/ UNICEF ), improved sanitation needs to be achieved in most of the ECD centres in the study area.
There are health risks associated with the unimproved sanitation such as the use of the bucket system, the close

CONCLUSIONS
The results confirm that while most of the ECD centres in the study area have access to improved water source, they lack adequate sanitation facilities and overall safe hygiene standards and behaviour are low.  is an urgent need for an integrated plan that creates room for active involvement and participation of parents, caregivers, government departments and non-governmental organizations which will provide a comprehensive age and developmental stage equivalent package for children and caregivers at ECD centres. This study strongly recommends that WASH messages become part of ECD practitioner training, environmental health promotion and the ECD curriculum, both at the centres and at home-based care environments. This suggestion compares well with a recommendation in a recent study, for an inclusive WASH training aimed at enhancing teachers' awareness of the barriers, challenges and enablers to WASH practices in schools to be emphasized (Zaunda et al. ). Workshops on WASH for parents, caregivers, principals, stakeholders and regular monitoring and promotion of WASH standards will be beneficial to the ECD centres in the study area. It is also recommended that ECD centres receive adequate support to improve the structural issues in order to meet environmental health standards and departmental regulations, in order to be registered as a quality partial care facility. At a country level, and in line with SDG6, an enabling environment for WASH is required that creates the conditions for sustainable, at-scale WASH services which will facilitate the achievement of the WASH Sustainable Developmental Goal of Universal Access for All, which can only be achieved with a progressive reduction in inequality and adequate water governance (UNICEF ).