Peri-urban schools of Kinshasa before and during COVID-19: an evaluation of water, handwashing facilities, and girl students’ hand hygiene practices

CI

confidence interval

COVID-19

coronavirus disease 2019

DRC

Democratic Republic of the Congo

EP

educational province

PUHZ

peri-urban health zone

PUSK

peri-urban settings of Kinshasa

SDGs

sustainable development goals

SGAG

school-going adolescent girls

SPSS

statistical package for social science

WASH

water, sanitation and hygiene

WHO

World Health Organization

In Africa, as around the world, the unexpected onset of the COVID-19 pandemic, its high rate of spread, its speed and magnitude, and its impacts have caught most countries off guard (WHO 2021). The COVID-19 pandemic has also led organizations to address various weaknesses and bring about organizational changes in many other sectors worldwide either during or after the lockdown (Frimousse & Peretti 2020).

Globally, the COVID-19 pandemic has caused an unprecedented upheaval in education systems, disrupting the lives, education, and well-being of nearly 1.6 billion students in more than 190 countries on all continents (UNICEF-WHO 2020). According to the United Nations (UN), the closures of schools and other learning spaces resulting from lockdown have affected 94% of the world's school population, and up to 99% in low- and lower-middle-income countries (UN 2020). As a result of the lockdown, just over 60% of school-age students were affected by school closures and the majority have missed more than a quarter of teaching (UNHCR 2020a, 2020b).

To address the spread of the coronavirus and to build resilience to the multiple impacts on the education and the disruption of many essential school services, several studies and jurisdictions, as well as UNICEF and WHO, when schools reopen, recommended a series of preventive measures that can effectively contribute to the response to COVID-19 and to stop the spread of other pathogens in schools (Brauer et al. 2020). Most of these measures are based on environmental components (Krishnaratne et al. 2020). Firstly, these measures recommend that schools improve hand hygiene, mainly through regular handwashing as an important preventative measure against the transmission of pathogens (Mathur 2011). Secondly, the supply of water, and thirdly, the application of decontamination procedures, emphasizing the disinfection of surfaces (Gupta & Lipner 2020). Others measures such as facial mask wearing, hygiene of latrines, and communication of risks surrounding COVID-19, implementation of appropriate environmental disinfection protocols and decontamination procedures were recommended (Melnick et al. 2020; UNICEF-WHO 2020). However, regular handwashing with soap and water is dependent on the water supply and the availability of handwashing facilities at the school level. Moreover, communication and awareness programmes were also found to be necessary for maintaining the recommended handwashing practices (Schmidt 2020).

The Democratic Republic of Congo (DRC) reported its first cases of COVID-19 in March 2020, hence the city of Kinshasa was the epicentre of the DRC outbreak (OMS-DRC 2020). To date, the various impacts are still felt in several sectors such as social, health, economic, educational, and tourism (Carter & Moncrieff 2021). As in other countries, the lockdown announced as one of the first measures to contain the spread of the pandemic has resulted in the closure of schools in the provinces most affected by the pandemic. Throughout the country, this closure has deprived more than 27 million children of their rights to education and information for more than a quarter of the school year (Carter & Moncrieff 2021).

The end of the lockdown decided by the government was followed by the reopening of schools and the resumption of school activities, on the condition that measures to prevent the spread of COVID-19 were implemented. These included general measures, including social distancing, wearing of face masks, the ventilation of classrooms, and WASH measures, including regular handwashing, supported by a supply of water and soap, handwashing facilities, and disinfection with hydro-alcoholic solution, training, and risk communication (WHO-UNICEF 2020). A study collecting WASH data from peri-urban schools of Kinshasa during the course of 2019 identified and showed many shortcomings that prevented students, especially girls, from meeting their hygiene needs in schools in peri-urban areas of Kinshasa. Shortcomings included the acute inadequacy of water points, handwashing facilities, soap, poorly maintained hygiene of latrines, and so on.

Thus, the COVID-19 outbreak, combined with existing WASH data, raises concerns about the capacity of peri-urban schools in Kinshasa to make changes to the school environment in order to contribute to efforts to control the spread of COVID-19 through the implementation of WASH approaches in line with national and international recommendations (WHO-UNICEF 2020). It is particularly important that schools should adopt correct handwashing procedures as the first line of defence against the spread of pathogens (Mathur 2011; Fries et al. 2020). This concern motivated this second study to acquire data to address the concern raised about whether peri-urban schools in Kinshasa have made changes through the implementation of recommendations to achieve resilience to COVID-19. In other words, are water supplies, handwashing kits, water, soap, and WASH brigades more available and improved in schools during the pandemic than before to promote hand hygiene to enable the prevention of the spread of pathogens such as the coronavirus within schools? Are school staff and students trained or sensitized enough about COVID-19? Are students, especially adolescent girls, adhering to handwashing practices more than before the COVID-19 pandemic?

This article compares data from interviews and field observations on WASH items from two studies. The goal is to determine institutional and behavioural changes carried out in peri-urban schools of Kinshasa in terms of their current capacity to face the spread of coronavirus and other pathogens transmitted through poor hand hygiene, based on the availability of environmental WASH items and WASH practices.

Two analytical and observational cross-sectional studies were performed sequentially in peri-urban settings of Kinshasa, targeting WASH facilities and girl students in schools of three out of four educational provinces (EPs) of the city of Kinshasa (Tshangu, Mont Amba, and Lukunga) before and during the COVID-19 pandemic.

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By predicting the rate of refusal, missing data at 15%, and adding a rate to improve the power of the test, up to 858 SGAGs were targeted. But data were collected from a sample of 684 SGAGs after removing 174 (20.3%) who refused to participate in the study despite their parents’ authorization.

In the first study participants’ selection was based on a 5-degree random sampling to successively select 6 out of 12 peri-urban health zones (PUHZ) in the three EPs, followed by a selection of 24 health areas, 4 in each of the 6 PUHZ. Thereafter we selected 120 streets from 24 health areas. On each selected street, a plot survey identified eligible households meeting the criteria of having at least one SGAG involved in water collection. Hence, the 684 SGAGs meeting the first study's inclusion criteria were questioned about WASH issues both in their households and their schools.

Afterward, a second study (the one before COVID-19) was implemented to establish links between the SGAGs and the schools they cited and attended, to investigate WASH issues as stated at the household level. Out of 187 schools mentioned by SGAGs at the household level, 165 (88.2%) meeting the study criteria of being located in peri-urban settings and not being connected to the industrial water supply network were surveyed.

To increase the likelihood of finding the changes sought between the two studied periods (before and during Covid-19), the research team chose to survey a larger sample corresponding to more than two-thirds of the 165 schools previously enrolled in the study before the COVID-19 outbreak.

Therefore, the third study randomly selected 111 peri-urban schools from the 165 schools previously studied, of which 56 schools were selected in Lukunga, 29 schools in Mont Amba, and 26 schools in Tshangu (Table 1).

The data displayed in Table 1 reveal that on average, there were significantly more girl students enrolled in schools during the COVID-19 pandemic period than before (P < 0.0001).

In the study before COVID-19, 4,290 adolescent girl students were selected from 165 schools based on 26 students per school. This represented one-quarter of the average number of adolescent girls per school. This proportion (25%) was chosen to include enough adolescent girls in each observation in a school during the two critical moments (after using the toilet and before eating). In the second study, 2,886 adolescent girl students were selected from the 111 schools qualified.

It should be noted that as the observations were derived from the qualitative approach of the study, the determination of the aforementioned number of girl students to be included in the observations of both studies was rationally reasoned, based on convenience sampling. To address this weakness, the research team opted to observe a large number of girl students to increase first the chance of a better hand hygiene practice understanding, and second, to confer on the study observations the inferential nature to other peri-urban schools given the statistical analyses performed.

The availability of water points and handwashing facilities and the existence of posters about WASH at the display points within the school were observed and checked as Yes or No. The practice of handwashing by adolescent girl students was also observed by an investigator. Therefore, hand hygiene was considered effective when performed using simultaneously ‘water and soap’ or ‘hydro-alcoholic disinfectant solution’.

Recommendations during COVID-19 on washing hands with soap and water every 2 h or as frequently as possible were also checked (Melnick et al. 2020). Due to time limitations, investigators could not remain in the schools to monitor handwashing continually, so we opted to measure handwashing by referring to two traditional critical times: before eating and after using the latrines (Dagne et al. 2019). Handwashing was observed during recess and other break times by two groups of investigators, all equipped with an observation grid. The first group was located not far from the handwashing facilities next to the latrines, to observe the handwashing practices of 13 girls per school after using the latrines. A second group, stationed in the schoolyard, observed the practice of handwashing before eating by13 other girls. For each group, the investigator recorded whether Yes or Not an observed adolescent girl student washed her hands after using the latrines or before eating.

Furthermore, the study assessed whether the school allocated funds, received other support for WASH activities, whether there was a predefined periodicity and whether funds were regularly deposited. The study considered the allocation of funds and support to be effective if all these conditions were met.

The functionality of a water point was assessed by the observation of the presence of water on the survey day. The functionality of the handwashing facilities was measured by their use with the presence of water and soap during the survey moment. Training and awareness-raising activities on WASH topics were evaluated by their inclusion in school curricula as well as on the school authorities’ statements. The existence of a WASH brigade was checked, and its functionality was checked by the presence of sensitization activities on WASH issues among school communities.

Among schools lacking water points in their yards, the time taken to travel to and from the water point was recorded by investigators based on the school workers’ or authorities’ estimation.

Data for the first study were collected from March to September 2019, and between June and August 2021 for the second study. Quantitative data were collected through interviews with school authorities using a standardized UNICEF/WHO school WASH paper questionnaire, pre-tested, and adapted to the local context (UNICEF/WHO 2016). Qualitative observational data were collected using a pre-tested observation grid.

The data collected during the two studies were entered on Epidata software version 3.1, then analysed with SPSS version 26.0. The normality of the distribution of quantitative variables was verified with Kolmogorov–Smirnov and Shapiro–Wilk tests (Razali & Wah 2011). The proportions of the two periods (Table 2) were compared with the Fisher–Irwin Chi-square test (Campbell 2007), and means (time of water collection and a number of handwashing facilities) were compared with the Student test (CI: 95%). A P-value < 0.05 was considered statistically significant for both tests. The relation between variables as well as the dependent and the independent variables (Table 3) was verified using the binomial logistic regression model or the Chi-square test (CI: 95%). Cramér's V for nominal data was used to measure the association strength when P < 0.05 in the Pearson Chi-square test. Hence, Chi-square values below 0.010 were considered to show a negligible association; from 0.10 to 0.20, a weak association; from 0.20 to 0.40, a moderate association; from 0.40 to 0.60, a strong association; from 0.60 to 0.80, a relatively strong association; 0.80 and under 1.00 as a very strong association (Kotrlik et al. 2011; P138).

The first study protocol submitted to the ethics committee of the Kinshasa School of Public Health was approved under the number ESP/CE/230/2018, and then completed by the number ESP/CE/230B/2021 for the improved version of the protocol to cover the second study. Informed consent and authorizations were obtained from the school headmasters and staff interviewed before performing each study. Approvals with educational province authorities were obtained in advance, and then referred to educational sub-province offices and school heads.

Data collected in 165 schools prior to COVID-19 and 111 schools during the pandemic are presented in the tables and figures below, displaying the WASH situation of the schools of three EPs of the city of Kinshasa.

Comparing the WASH items assessed before and during COVID-19, Table 2 shows changes recorded for items such as the increased proportion of water points (P = 0.0093); the proportion of handwashing facilities (P < 0.0001); schools having handwashing facilities next to the toilets (P < 0.0003); the average of handwashing facilities in schools (P = 0.0009); the proportion of schools with WASH school brigades (P < 0.0001); the proportion of schools allocating funds to WASH (P < 0.0001); and the proportion of schools receiving support for WASH activities (P < 0.0001). Of all donations received by schools, 45% were handwashing kits and 27% were liquid soap and disinfectants.

From the rest, data displayed in this table indicate numerical progress on all other WASH items assessed, but statistically did not demonstrate a significant difference between the two compared periods.

The observations of handwashing practices show that 89% (n = 4 290) of the girls observed washed their hands with ‘water only’, before the COVID-19 pandemic. This proportion with a decrease in practice trend is significantly higher than 76.4% (n = 2 886) during the pandemic (P = 0.0003). However, 11% of girls washed their hands with ‘soap and water’ before the pandemic compared to 20.3% during the COVID-19 pandemic (P = 0.0049). The proportion of girls observed performing hand hygiene with a ‘disinfectant solution’ during COVID-19 was 3.3% compared to 0% before the COVID-19 pandemic (P = 0.0059).

The data displayed in Table 3 show that the practice of handwashing among adolescent girl students in schools in the study area depended on the presence of a functional water point within the school (P = 0.006); the presence of water in handwashing facilities (P = 0.017); the presence of soap next to the handwashing facilities (P = 0.000); the simultaneous presence of water and soap (P = 0.003); and the allocation of funds to maintain WASH infrastructures (P = 0.048). The strength of the association between handwashing practice and allocation of funds to WASH activities was weak, while the association between handwashing practices and variables such as the possession of a water point and the availability of water and soap in the handwashing facilities was moderate.

Data in the table also show that the numerical increase of handwashing facilities in a school increases the likelihood of adolescent girl students washing their hands in school at least once.

This study was undertaken to document changes in WASH items and hand hygiene practices among adolescent girl students in Kinshasa peri-urban schools in response to national and international recommendations to curb the spread of COVID-19. The results in this study showed moderate changes through the indicators assessed. The majority of these changes are clearly significant when comparing the current data with the previous baseline study as illustrated in Table 2 and Figure 1.

The proportion of female students who washed their hands before the period before COVID-19 was very low, and this increased by about 5% during COVID-19. This increase in handwashing is associated with the increase in the number of schools with water points, handwashing facilities, and so on (Table 3). This finding is similar to many previous studies not always performed in peri-urban schools, but showing that increasing the number of handwashing facilities and their functional quality improves handwashing practice after a WASH intervention in schools (Chittleborough et al. 2012; Wichaidit et al. 2019). Our study also showed a dependent link between handwashing practice and the availability of both water and soap in handwashing facilities. This result is similar to the results from a study on hand hygiene practice among students with the availability of water and soap within handwashing facilities in primary schools in Kenya (Saboori et al. 2013).

As far as effective handwashing is concerned, nearly three out of 10 adolescent girl students observed during the COVID-19 period washed their hands both after using the latrine and before eating (Figure 1). This result is similar to those reported by students in Bogotá, Colombia, who responded to an anonymous self-administered questionnaire, in which 33.6% of students indicated that they used both soap and water when washing their hands (Lopez-Quintero et al. 2009).

Awareness-raising interventions and reminders about the importance of handwashing have been found to have a positive impact on handwashing as well as the post-intervention and during follow-up (Chittleborough et al. 2012; Fries et al. 2020). However, in contrast to these results, our study showed that handwashing practices did not depend on awareness-raising activities and posters in schools (Table 3). We assume that most of the above results are based on limited samples, qualitative studies, self-reported data, or self-administered questionnaires, and that the current study involves two studies in the same context, using a large direct observational component on handwashing practice which involved 7,176 girl students could explain the discrepancies between findings from peri-urban schools in Kinshasa and those reported elsewhere.

The results concerning handwashing practices show that almost 9 out of 10 girl students observed before the COVID-19 pandemic washed their hands with only water, without soap. The second study demonstrates a decrease of at least 10% during the COVID-19 pandemic with an increase in handwashing practice. This is also consistent with the increased proportion of girl students found washing their hands with soap and water from 1 in 10 female students to 2 in 10 girl students observed during COVID-19. However, our result is significantly lower than the 54.9% of students in Ghana's senior schools who were observed washing their hands with soap and water (Dubik et al. 2021). Several facts may explain the low proportion reported in Kinshasa, including the absence of a systematic intervention covering all the peri-urban schools considered in our study. Furthermore, in the surveyed schools, WASH interventions tended to be sporadic rather than systematic, which resulted in a low proportion of schools having water points, permanently available water, handwashing facilities, soap, and other WASH materials that have proven to be determinants in improving handwashing practices among students (Table 2). While in other reported contexts, students were observed in schools that benefited WASH interventions, and therefore systematically disposed of water and soap in their handwashing facilities. We assume that reinforcing such interventions would probably impact handwashing practices, as positive associations are shown in Table 3.

In relation to critical handwashing times, our study reported a slightly higher proportion of students washing their hands after using the latrine than before eating (Figure 1). The trend here is similar to that described in other contexts such as Ethiopia, where students were more likely to wash their hands after using latrines than before eating (Vivas et al. 2010). In the context of Kinshasa, the data at our disposal do not allow us to explain this trend among adolescent girl students. A qualitative study is suggested to better understand the main motivation to explain such practice.

We do think that in a context where the COVID-19 pandemic persists, evolving from wave to wave, increasing the urgency of the need to promote preventive measures to strengthen resilience in school environments, Kinshasa's peri-urban schools would gain in strategies if efforts were invested in promoting handwashing among school communities, particularly after latrine use, as a community point of transmission, and spread of COVID-19 between latrine users through frequent contact sites such as door handles, sink taps, and paper dispensers or after handling surfaces potentially contaminated with pathogens such as COVID-19 (Amirian 2020; UNICEF-WHO 2020; Dancer et al. 2021).

This study has only assessed two times supposed critical to handwashing practice in schools. The study was not able to continuously monitor the supposed handwashing practice as long as was wished in the schools to determine the effective proportion of handwashing of female students due to the lack of time spent by the investigators in the surveyed schools. We also aimed to prevent the Hawthorn effect by undertaking the observations without the girls’ awareness, which meant that the investigators were under a time constraint. In addition, WASH items such as mask-wearing, disinfection of surfaces, and social distancing were not assessed in the baseline 2019 study; therefore, these items were not assessed in this 2021 study to ensure that the indicators were comparable, although we acknowledge that these indicators could provide a better understanding of the global response of schools to the COVID-19 pandemic. Another limitation was due to the lack of a largely qualitative approach which would, through focus groups and deep interviews, allow a better understanding of the motivations of the low level of girl students’ handwashing practice in schools especially before eating and after latrine use.

In comparison to the results of the previous WASH study, schools in the study area have gained significantly and numerically in the increase of some WASH items during the COVID-19 outbreak. However, the current hand hygiene practices, which depend on a range of WASH items and interventions, seem unlikely to be effective in containing the spread of COVID-19, and in contributing to sustainable resilience to the negative impacts of the COVID-19 pandemic. Additional interventions targeting water points, functional handwashing kits, and hand hygiene awareness and practices are required to increase the current WASH item coverage, and improve handwashing practices as key components to be taken into consideration by school authorities to improve the current WASH portrait in peri-urban schools of Kinshasa, as an essential step towards achieving the SDGs by 2030.

These findings suggest that more extensive studies covering other WASH items that were not assessed here, and involving other schools in central settings of Kinshasa, not subject to water collection chores, would provide additional information on schools’ overall resilience to the various impacts, and the spread of COVID-19 and other pathogens.

The authors are deeply grateful to Marie-Christine Brault from UQAC for her high involvement in this article process, including Trésor KODI M who supervised the field data collection as well as Cécile M'buyamba M, Agathe Bawamio B, and Merveille Koko who conducted field interviews and observations.

JMM and GKM designed the study, drafted the study protocol, and coordinated the data collection. JMM and TNM analysed the data and drafted the article, MYK, JKN revised the French version while JMM, MYK, and GKM revised the English version until the article was submitted for publication.

The production of this article was self-funded.

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

The authors declare there is no conflict.