Water, sanitation, and hygiene conditions in schools in Antalya in Turkey: a descriptive survey^†

Water, sanitation, and hygiene (WASH) services are critical to health, and schools must focus on improving WASH to ensure that their students stay healthy (WHO 2022). Children have a better environment for learning and fulfilling their full potential when they have facilities such as clean water, toilets, and soap for washing hands at school (UNICEF 2018). However, UNICEF and WHO reported that inequalities persist between and within countries, despite the continued decline in the proportion of schools without basic WASH services (WHO 2022).

Schools with adequate WASH facilities should have a safe and adequate water system for handwashing and drinking, sufficient private, safe, clean, culturally and gender-appropriate toilets for students and teachers, and adequate and clean handwashing facilities (McMichael 2019). Unfortunately, it has been reported that there are no suitable WASH conditions in schools on all continents in the world, and that even when the infrastructure is available, the amount is not sufficient, and it is not suitable for maintaining and improving the health of the school community (Poague et al. 2022; WHO 2022). Globally, 600 million children lack basic drinking water and sanitation, and 900 million children are deprived of basic hygiene services in their schools (UNICEF 2018). However, it is known that improving water, hygiene, and sanitation conditions in schools improves children's health and reduces absenteeism (Sharma & Adhikari 2022).

In Turkey, a ‘White Flag’ certificate with a validity period of 2 years is given to schools that meet the criteria determined in cooperation with the Ministry of Health and the Ministry of National Education to encourage schools about cleanliness and hygiene and to improve school health (Ministry of National Education 2010). However, most of the schools cannot obtain this certificate due to inadequate physical infrastructure and resources, and approximately one-third of them have this certificate (Çetinkaya et al. 2020). In our country, resources are provided to schools by the state. However, public resources are not sufficient to solve the economic problems that schools experience, so schools have to receive support from different institutions and organizations (Ministry of National Education 2010; Özdoğan Özbal 2017). In addition to the resources provided by the state, schools receive services from local administrations and meet the needs of students' parents (school−parent association) specified as private financial resources by using the payments made or private donations made (Gürel & Sarışık 2022). As a result of the study carried out by the Ministry of National Education in 21 provinces belonging to seven geographical regions, it was determined that most of the cleaning material needs of schools (89.9%) were met by the school−parent association (Ministry of National Education 2010). In addition, many schools in our country do not have health offices, and no health workers, especially school health nurses, are employed (Töre 2019; Çetinkaya et al. 2020).

It is known from the studies conducted in Turkey that schools are crowded, the cleaning services are not sufficient, schools have difficulty in meeting the need for tools and equipment used in cleaning, and the number of cleaning personnel is insufficient. In addition, it has been reported that the number of toilet cubicles per student is not sufficient, there is a shortage of sanitation and cleaning materials in the toilets, and the students meet their drinking water needs from the sinks in the toilets (Ministry of National Education 2010; Arslan 2018; Çetinkaya et al. 2020; Sezer Balcı et al. 2020). Schools in Antalya, which is the province with the third highest number of immigrants in our country due to its geographical location, are also faced with personnel problems, in addition to the inadequacy of physical infrastructure and materials, due to the increasing number of students. Therefore, this study aims to determine the cleaning, hygiene, and sanitation conditions of schools in Antalya. It is thought that the results of this study will provide important data in terms of revealing regional problems and discussing solution proposals for maintaining a healthy and reliable education environment in schools in this province.

This study, which was conducted to determine the cleaning, hygiene, and sanitation conditions of schools in Antalya, was designed as a descriptive study.

The population of the study consists of principals of 1,244 public and private schools in 19 districts of Antalya. Principals of all schools in Antalya were included in the sampling and students were not included. 480 school principals filled out the questionnaire and the participation rate was determined as 38.6%. Looking at the studies conducted by distributing questionnaires, it is known that the average online questionnaire response rate is around 30% recently (Cleave 2020). The number of participants reached in this study was found to be compatible with the literature in this context.

The data of the study were collected with the ‘Water, Cleaning and Hygiene Questionnaire for Schools’ created by the researchers, using the research and literature information on the subject. The questionnaire consisted of three parts: (1) introductory information for schools (location, type of education, number of students and employees, supply of cleaning personnel and materials, drinking water supply, and pest control program); (2) cleaning and hygiene practices for various areas (the frequency of cleaning the garden, corridors, classrooms, teachers' room, library, lab, gym, and toilets and the methods used), and (3) cleaning and hygiene conditions of toilets (number, cleanliness, availability of hygienic materials, etc.). The questionnaire consisted of multiple-choice questions and open-ended questions, and the school principals were asked to answer the questions. In cases where more than one option was ticked in some questions, such as the toilet cleaning method, evaluations were made by considering the total number of answers. The data of the research were obtained based on the self-reports of school principals between June and July 2017. The form could be filled in 15–20 min.

Statistical Package for the Social Sciences software was used in analyzing the data. Number, percentage, mean, and standard deviation were used. According to the rules set by the Ministry of National Education in Turkey, schools must have a cubicle for every 20 female students, a cubicle and two urinals for every 40 male students, and a washbasin for every 60 students. According to the number of cubicles and washbasins available, the school is defined as ‘Sufficient’ if it meets this criterion, and ‘Insufficient’ if it does not.

Prior to conducting this study, the researchers signed the Declaration of Helsinki developed by the World Medical Association and obtained institutional permission from Akdeniz University Clinical Research Ethics Committee (Decision: 14.06.2017, No:382) and the Antalya Provincial Directorate of National Education. In addition, a written informed consent was obtained from the principals included in the study.

In this study, the water, cleaning, and hygiene conditions of the schools were evaluated according to the written statements of the school administrators, i.e., the answers they gave to the questionnaires, and no observations and examinations were made in the schools. This situation was considered an obstacle to the elimination of the bias in the answers given by the school principals.

In this study, it was found that 82.5% of the schools included in the sample provided full-time education, 91.7% were public schools, 53.8% were in districts outside the central districts, and the rates of primary and secondary schools were higher (25.9 and 25.3%, respectively). The number of students and teachers in the schools in the central districts was nearly twice that of the schools in the rural districts. Therefore, the number of students per school in the city center is higher. The ratios of male and female students in schools in the central and rural districts were close to each other. The ratio of female teachers in schools in the central districts was higher than both male teachers and those in the rural districts (Table 1). It was determined that in 59% of the schools, the students used the fountain in the garden or the building as a source of drinking water. However, in 34 schools (4%), students met their drinking water needs from the taps in the toilets. In addition, it was determined that only 37.1% of the schools had a programmed pest control program, 32.1% had permanent cleaning personnel, and the cleaning materials were mostly (51.2%) obtained from the school council budget. It was determined that only 16.0% of the schools had health offices and 36.8% of them had no staff (Table 2).

In 63.7% of the schools, there were toilets on each floor for students, 63.3% of these toilets had toilet paper, most of them had waste bins (89%) and liquid/foam soap (98.5%), but the numbers of handheld paper towels (47.7%) and hand dryers (2.1%) were found to be low (Table 3). Table 4 shows whether the schools had a recommended number of sinks and toilets according to the Turkish standards. According to this, only 42.3% of the schools had enough toilets for female students, while 72.8% had enough toilets for male students. According to the total number of students, the ratio of toilets in schools was lower for both female and male students in the central district schools. The ratio of sinks in schools according to the number of students was better than the ratio of toilets (87.7% for girls and 85.7% for boys), and these rates were also lower in the central district schools. On the other hand, it was seen that 92.5% of the schools did not have the recommended number of toilets for female teachers, while 82.8% had the recommended number for male teachers, and therefore, female teachers were more disadvantaged (Table 4).

When children have access to clean water, toilets, and soap at their school, they have a better environment to learn and realize their full potential (UNICEF 2018). In this study, in which the hygienic conditions of schools in Antalya were investigated, it was determined that the schools' clean drinking water supply, regular pest control program, permanent cleaning personnel, supply of cleaning materials, and number of toilets were not adequate.

A basic drinking water service in schools means having water from an efficient reliable source. However, according to UNICEF's ‘Drinking Water, Sanitation and Hygiene in Schools: 2018 Global Status Report’, only 69% of schools have a basic drinking water service on a global scale (UNICEF 2018). In our country, 93.8% of the water sources used in schools is ‘tap water’ (Ministry of National Education 2010). In this study, it was determined that 59% of the schools used tap water as a drinking water source, but that some schools (33%) also had a water dispenser. This difference in the rates of drinking water sources is thought to be related to the status of the school. Since private schools in our country have more resources than public schools, they can offer their students opportunities such as water dispensers as a source of drinking water. In addition, the fact that students in 34 schools (4%) met their drinking water needs from the taps in the toilets is a very important finding in terms of infection risk. Because of these points of use, it is possible for the water to be polluted (Shrestha et al. 2017). Similarly, in the study conducted throughout the country, it was determined that 10.3% of students met their drinking water needs from the fountains in the toilets (Ministry of National Education 2010).

Schools are vulnerable to pests since their buildings are large and may be neglected, serve large numbers of people, and store, prepare and consume food in them (US Environmental Protection Agency 2022). Therefore, planned pest management practices are needed in schools both to reduce the risks to students and staff from pesticide exposure and to minimize pest damage to structures and personal belongings (Maryland Department of Agriculture 2020). However, it is known that even in developed countries, there is no clear school-specific model in this regard, and planned and regular practices in schools are limited (Jones & Glick 2018). As a result of the nationwide study conducted by the Ministry of National Education in Turkey in 2010, it was stated that only 34.2% of schools had a programmed prevention/destruction program and that pests were sometimes seen in 35.4% of schools (Ministry of National Education 2010). Similarly, in this study, it was determined that only 37.1% of the schools had a programmed pest control program, while more than half had schools sprayed if needed. Since schools do not have sufficient budgets for programmed pest control, school administrators provide pesticides in schools, mostly by getting support from the local governments (municipalities) for pests in schools (Özdoğan Özbal 2017).

It was determined that only 16.0% of the schools had health offices, and most of them had no health workers or teachers assigned. In our country, there is usually a health office in private schools, but the number is very low in public schools. Only 8.9% of primary schools have a health office in Turkey (Ministry of National Education 2010). However, it is very important to employ health workers, especially school nurses, in schools, because school nurses are in a unique position to collaboratively assess needs in the school, collect data for solutions, advocate for better health, and evaluate outcomes. School nurses can expand their sphere of influence by working across sectors, professions, and disciplines to create a culture of health at school and improve health outcomes, thus contributing to the solution of schools' resource constraints (Bergren 2017; NASN 2018).

Cleaning staff in schools are important employees in terms of providing a clean, hygienic, and safe environment for students and staff. It is known that 57.6% of the cleaning personnel in schools in our country are permanent and that in schools without cleaning personnel, an attempt is made to fill this gap by allocating contracted personnel or by purchasing services. Similarly, it is known that 89.9% of the cleaning material needs of schools in our country are met from their own budgets obtained by the school council (Ministry of National Education 2010). In this study, it was determined that only 32.1% of the schools had permanent cleaning personnel and that the cleaning material needs were mostly (51.2%) met from the school council budget. This situation may cause difficulties in meeting the cleaning materials and cleaning personnel needs of the schools and disrupt the services.

A basic sanitation service in schools can be realized if schools have available and gender-specific advanced sanitation facilities. Globally, however, only 66% of schools provided single-sex sanitation in 2016 (UNICEF 2018). In this study, there were enough toilets for female students in only 42.3% of the schools and for male students in 72.8% of the schools, and the rates were significantly lower in schools in the central districts. This situation is thought to be due to the old school buildings, the lack of capacity to serve the increasing number of students, and the lack of new arrangements according to the student profile as gender in Turkey (Göksoy 2017). In this study, although the ratios of male and female students in schools in central and rural areas are close to each other, the number of cabins for both genders, especially for girls, was insufficient due to the high number of students in schools in the city center. According to the regulations in our country, a cabin should be provided for every 20 female students, but a cubicle and two urinals for every 40 male students in schools. In addition to the differences in these rates, the use of a wall-mounted urinal together with the cabin for male students may have made them more advantageous in this regard, as it provides space savings. In addition, in this study, it was determined that teachers were more disadvantaged than students in terms of adequate cabin supply. It was determined that there was not enough cabin for teachers of both genders, especially female teachers in schools in the central districts. Since the rate of female teachers in schools in central districts is higher than both male teachers and schools in rural districts, it is expected that they will be more disadvantaged. This situation may cause significant problems, especially for female students and teachers who are at high risk of genitourinary infections. In order to prevent the entire school population, especially these vulnerable groups, from being adversely affected by inadequate sanitation conditions, urgent steps should be taken to accept students according to their capacities and improve sanitation conditions according to the student profile. At least, ensuring the continuity of hygienic materials and cleanliness, as well as raising awareness about hygiene should be the first steps to be taken. Although there are practices such as giving the ‘White Flag’ certificate as a reward to encourage and supervise schools in terms of cleanliness and hygiene in Turkey, most of the schools cannot receive this certificate due to insufficient physical infrastructure and resources (Ministry of National Education 2010; Çetinkaya et al. 2020). However, it is expected that the guides on ‘Improving Hygiene Conditions in Educational Institutions and Infection Prevention Control Guide’ and ‘Precautions to be Taken in Schools During the Epidemic’ published by the Ministry of National Education are expected to guide the prevention of infection and ensuring hygiene in schools (Ministry of National Education 2020, 2021). At the same time, taking water samples from the mains water and water tanks used in schools in our country once a month by the Ministry of Health facilitates the rapid taking of measures for unsafe drinking water sources (TC Resmi Gazete 2005).

Basic hygiene services in schools can be provided if the schools have a handwashing facility with soap and water (UNICEF 2018). In this study, while the number/quantity of sinks, liquid/foam soap, toilet paper, and waste bins in the toilets of the schools were sufficient, the rates of paper towels and hand dryers for drying hands were found to be low. Similarly, in the study conducted across the country, it was stated that 92.8% of schools' student toilets always had waste bins, 66.8% of them had liquid/foam soap, and 17.2% of them had toilet paper (Ministry of National Education 2010). However, since dirty and smelly toilets and the lack of hygienic materials are factors that affect the use of school toilets by students, it is important to eliminate hygiene and material deficiencies to prevent urinary system problems in children (Sezer Balcı et al. 2020).

Schools are a major source of infection as crowded places where students and staff spend most of their time during the day. Especially in cases where water, hygiene, and sanitation conditions are inadequate, the risk of person-to-person transmission will increase, making schools high-risk environments for students and staff. For this reason, it is important to provide clean drinking water, hygiene, and sanitation services to protect students and staff from diseases in schools. In this way, students can study in a healthy and safe environment. However, it was seen that the schools in Antalya had problems in supplying the necessary materials, tools, services, and personnel to provide hygiene and sanitation conditions and that they tried to find temporary solutions to meet these needs. To encourage and facilitate effective WASH coverage and implementation in schools, it is important to support schools with supplies, equipment, and cleaning staff.

We are grateful for the contribution of all school administrators.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Akdeniz University Ethics Committee (14.06.2017 dated, Approval No: 382).

The authors declare that they have received no financial support.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.