This pilot cross-sectional study was conducted to assess water and sanitation hygiene-related knowledge, attitude and practices (KAP) among rural school students in Chennai, South India in September 2013. A convenient sample of 80 participants (70 children and 10 staff members) was enrolled in the study. The inclusion criteria included participants residing in rural areas and studying in a government school. A semi-structured questionnaire was used to assess sociodemographic and school characteristics and water and sanitation hygiene (WASH)-related KAP. The mean age of the students was 14 years (SD = 2) and half of them were females. The school had a government drinking water supply and did not use any water treatment/purification method. The majority of the participants had correct WASH-related knowledge. However, one-third of the students reported diarrheal episodes in the school due to unsafe drinking water. There was disparity in the response of the students compared to the staff about toilet facilities in the school. This study concluded that there is a need for multifaceted intervention that will facilitate adequate water and sanitation hygiene practices among school children through the availability of proper sanitation infrastructure and family-centered education.

INTRODUCTION

Around 2.65 billion people globally live without access to proper toilet facilities and 883 million do not have access to safe water (DISE 2012). The World Health Organization (WHO) listed diarrheal diseases at fifth position in the list of top diseases of leading causes of deaths around the globe (WHO 2013). Ninety percent of the deaths in children under the age of 5 years are due to diarrheal diseases, poor water quality, sanitation and hygiene. Of these 2,000 deaths every day, 240 children are dying in India itself (UNICEF 2013). Improved water supply and sanitation can contribute to a 23 and 36% decrease, respectively, in morbidity due to diarrhea (DISE 2012), and a gain of about 2 billion school days (UNICEF 2012). Findings from an earlier meta-analysis revealed that hand-washing practice and hygiene-knowledge promotion contributes to a 44 and 42% reduction in morbidity due to diarrhea, respectively, implying that hand washing at critical times can prove vital (Fewtrell et al. 2005; DISE 2012).

Open defecation worldwide has decreased from 24 to 15% in the last two decades (WHO & UNICEF 2013). The declining trend in open defecation is a sign of improvement; however, other important factors such as hygiene practices should also be addressed. Availability of sanitation facilities in developing nations is markedly reduced compared to developed nations (UNICEF 2012), and compared to the global scenario the trend of open defecation in rural India still lags behind. In India less than 50% of the population has improved sanitation facilities and 66% of the rural population still practiced open defecation in 2011 (WHO & UNICEF JMP 2013). Water and sanitation hygiene (WASH) facilities in the schools in India do not show a fair improvement (ASER 2013). The Annual Status of Education Report (ASER 2013) notes that in 2012 toilet facilities in rural schools comprised 56% useable toilets for all and a mere 48.2% of separate usable toilets for girls. Over a fifth (21%) of Indian schools did not have separate provisions for girls' toilets. Across the country, 84% of schools had a drinking water facility but only two-thirds of the schools had separate toilet facilities for girls. In the state of Tamil Nadu, the rural area showed 13.4% of schools with no provision of separate toilets for girls and 11.2% of schools with no provision of clean drinking water (ASER 2013; UNICEF 2012; UNICEF ROSA 2012).

An estimate by a group of researchers (Bhutta et al. 2013) shows that 95% of the diarrhea could be prevented by 2025 by scaling up highly cost-effective intervention. Use of improved and clean sanitary facilities, washing hands with soap after toilet use, decreases the risk of fecal–oral disease by almost 40% (UKAID 2013), with the estimated cost for these efforts put at US$6.7 billion (Brown et al. 2013; Bhutta et al. 2013). Provision of water facilities and sanitation does not ensure health and hygiene, but the functionality is the root cause. There are some major gaps between the provision and function of these facilities: of the 93% of schools with provision for clean drinking water, only three-quarters of the facilities were functional, and similarly of the 80% of schools with toilet facilities only 61% were functional (WHO & UNICEF 2006).

Regular monitoring and education within schools for children may prevent occurrence of morbidity and mortality related to quality of water, sanitation and hygiene. To the best of our knowledge, these factors were not addressed in previous findings. Lack of adequate knowledge and poor WASH-related practices may affect the health of a child. WASH in schools is a way of improving access to quality education (UKAID 2013). Efficiency of learning, increase in school attendance and overall performance of children are all linked to awareness about health and WASH-related practices. Direct engagement with students can lead to community adoption of good WASH behaviors and technologies as well as improved health. Children are agents of change; education for good hygiene practices in schools links students, families and communities (DISE 2012).

The objective of this pilot study was to assess WASH-related knowledge, attitude and practices (KAP) among rural schools in an Indian setting.

METHODOLOGY

A pilot cross-sectional study was performed during September 2013 in the rural school setting at Poonamallee in Chennai, a Southern state of India. The school is situated in the remote villages in the outskirts of the Chennai city. A convenient sample of 80 participants comprising 70 children and 10 staff members was enrolled in the study. The inclusion criteria included participants residing in rural areas and studying in a government school.

A total number of 2,276 students attended the school. There are 58 toilets with 50 toilets for the students and 8 toilets for the school staff. There were 23 toilets for the boys and 27 toilets for the girls. There were equal numbers of toilets for the male and female staff. There are two breaks in a day, one starting at 11:00–11:10 a.m. and the other starting at 12:50–1:50 p.m. The morning break time is not sufficient for the students; however, the lunch break is sufficient for all the students to enter the facilities. Permissions are given by the teachers to use the facilities even after the break time is exceeded. If the students do not have time to line up in the queue, they do their necessities as open defecation during breaks. The drinking water supply is a corporation water supply. However, the government has also installed a reverse osmosis water system in the school. The actual water source is a groundwater bore well and its depth is about 20 feet (∼6 m). The capacity of the water tank is about 16,000 l. The students and teachers drink from the same water source, i.e. groundwater. The hygiene education is provided at schools within the social science curriculum.

Participants were informed about the study purpose and those eligible and agreeing to participate were enrolled in the study. Consent and assent forms were obtained. Individuals who were mentally or physically challenged were excluded from participating in the study. The study protocol was approved by the institutional review board (IRB) of the Foundation of Healthcare Technologies Society, New Delhi (IRB#FHTS/032/2013).

Data collection tools

A modified questionnaire was prepared from the existing validated tools (WHO & UNICEF 2006). It consisted of the following content.

Sociodemographic characteristics

Information was gathered about age (years), gender, education status (Grade 6–8, Grade 9–10 and Grade 11–12) and number of family members in the household.

School characteristics

Information was gathered about school timings, recess time and duration, source and availability of water in school, water treatment/purification methods in school, frequency of water treatment, sanitation (toilet) facility type and number of toilets (boys, girls and staff) and facility for adolescent girls in the school and education on water and sanitation hygiene.

WASH perception and practices

Information was gathered about participants' perception and practices toward quality, storage and treatment of available drinking water. Information was also gathered about toilet facilities, hand washing and effect of sanitation and hygiene practices on health.

Additional information gathered included effects of unsafe drinking water on health and the various necessary measures to prevent its harmful effects.

Statistical analysis

Descriptive analysis was performed using univariate statistics to report means and standard deviations for the continuous variables and frequency distribution for the categorical variables. T-statistics was performed to compare differences in the continuous variables and chi-square analysis was performed to compare the frequency of categorical variables. All analyses were performed using SPSS version 16.

RESULTS

The results showed that the average age of the student participants was 14 years (SD = 2; N = 70) and 50% of them were females. Fourty-two percent of the students were from Grade 6–8 (N = 30) and 29% were from Grade 9–10 (N = 20) and Grade 11–12 (N = 20) (Table 1).

Table 1

Sociodemographic characteristics of students and school staff

Variables Students School staff 
Age Mean = 14, SD = 2 Mean = 42, SD = 9 
Gender (females) 50% (N = 35) 50% (N = 5) 
Education status 
 Grade 6–8 42% (N = 30)  
 Grade 9–10 29% (N = 20)  
 Grade 11–12 29% (N = 20)  
Household members Mean = 4, SD = 1 Mean = 5, SD = 2 
Variables Students School staff 
Age Mean = 14, SD = 2 Mean = 42, SD = 9 
Gender (females) 50% (N = 35) 50% (N = 5) 
Education status 
 Grade 6–8 42% (N = 30)  
 Grade 9–10 29% (N = 20)  
 Grade 11–12 29% (N = 20)  
Household members Mean = 4, SD = 1 Mean = 5, SD = 2 

School hours were from 9 a.m. to 4 p.m., with two recesses (first of 10 minutes, and second of 1 hour). The school had a government drinking water supply and did not use any water treatment or purification method. Eighty-seven percent (N = 61) of student participants and 100% (N = 10) of staff participants agreed that no water quality testing was being done in the school. One-hundred percent of the respondents agreed that the source of water for students and teachers was different. One-hundred percent (N = 10) of the staff agreed that the school provided education on water and sanitation facilities while only 57% (N = 40) of student participants agreed on this. Separate closed-type toilets were available for staff (N = 2), boys (N = 4) and girls (N = 2) (Table 2).

Table 2

School characteristics

Variables Students Staff 
What are the main sources of water on school premises? 
 Govt. water supply 100% (N = 70) 100% (N = 10) 
Is any water treatment/purification method being used in the school for purifying water? 
 No 100% (N = 70) 100% (N = 10) 
Is water quality testing being done in the school? 
 Yes 13% (N = 9)  
 No 87% (N = 61) 100% (N = 10) 
Do the students and teachers drink from the same water source? 
 No 100% (N = 70) 100% (N = 10) 
Is drinking water available in classrooms? 
 No 100% (N = 70) 100% (N = 10) 
Does the school provide any type of education on water and sanitation? 
 Yes 57% (N = 40) 100% (N = 10) 
 No 43% (N = 30)  
What type of toilet facility is available in the school premises? 
 Closed 100% (N = 70) 100% (N = 10) 
Total number of toilets in the school premises 
 Total toilets girls (2) 100% (N = 70) 100% (N = 10) 
 Total toilets boys (4) 100% (N = 70) 100% (N = 10) 
 Total toilets staff (2) 100% (N = 70) 100% (N = 10) 
Are hand-washing practices taught to you in the school? 
 Yes 91% (N = 64) 100% (N = 10) 
 No 9% (N = 6)  
Variables Students Staff 
What are the main sources of water on school premises? 
 Govt. water supply 100% (N = 70) 100% (N = 10) 
Is any water treatment/purification method being used in the school for purifying water? 
 No 100% (N = 70) 100% (N = 10) 
Is water quality testing being done in the school? 
 Yes 13% (N = 9)  
 No 87% (N = 61) 100% (N = 10) 
Do the students and teachers drink from the same water source? 
 No 100% (N = 70) 100% (N = 10) 
Is drinking water available in classrooms? 
 No 100% (N = 70) 100% (N = 10) 
Does the school provide any type of education on water and sanitation? 
 Yes 57% (N = 40) 100% (N = 10) 
 No 43% (N = 30)  
What type of toilet facility is available in the school premises? 
 Closed 100% (N = 70) 100% (N = 10) 
Total number of toilets in the school premises 
 Total toilets girls (2) 100% (N = 70) 100% (N = 10) 
 Total toilets boys (4) 100% (N = 70) 100% (N = 10) 
 Total toilets staff (2) 100% (N = 70) 100% (N = 10) 
Are hand-washing practices taught to you in the school? 
 Yes 91% (N = 64) 100% (N = 10) 
 No 9% (N = 6)  

Perceptions of WASH

Sixty-one percent (N = 43) of the students and 100% (N = 10) of the school staff perceived the drinking water to be safe (Table 3). More than half of the students (61%; N = 43) and school staff (60%; N = 6) agreed that quality of water can affect health; however, 40% (N = 4) of the school staff did not know about this. Student participants reported boiling water (56%; N = 39) and use of cloth (33%; N = 23) as useful options to have clean water. Sixty percent (N = 6) of the school staff reported chlorine as the best method to treat impure water. Forty-six percent (N = 32) of the school students believed that the water storage container should be cleaned every day compared to the 70% (N = 7) of the school staff that suggested it should be cleaned every 3 months. Seventy-one percent (N = 50) of the students and 100% (N = 10) of the school staff agreed that best practice is to drink water with a clean container and that water should be stored in a closed container. Only a few students (21%; N = 15) and school staff (10%; N = 1) reported suffering due to poor unsafe drinking water. The majority of the school students (36%; N = 25) and school staff (90%; N = 9) were satisfied with the present drinking water conditions. More than half of the students (59%; N = 41) and school staff (90%; N = 9) agreed that drinking water in school met their daily requirements. There was disparity in the response of the students compared to the staff about toilet facilities in the school. One-hundred percent of the school staff (100%; N = 10) compared to the 71% (N = 50) of the students found toilet facilities satisfactory (Table 3).

Table 3

Perception of water and sanitation hygiene

Variables Students Staff 
What do you think about drinking water in your school? 
  Safe for drinking 61% (N = 43) 100% (N = 10) 
  Unsafe for drinking 13% (N = 9)  
  Can't say 26% (N = 18)  
Do you think quality of water can affect health? 
 Yes 61.4% (N = 43)  
 No 31.4% (N = 22) 60% (N = 6) 
 I don't know 7.2% (N = 5) 40% (N = 4) 
What should be done to clean water? 
 Use water purifying systems 34% (N = 24) 10% (N = 1) 
 Boil 56% (N = 39) 20% (N = 2) 
 Use cloth filter 33% (N = 23) 10% (N = 1) 
 Use chlorine 10% (N = 7) 60% (N = 6) 
 Do nothing 3% (N = 2)  
 I don't know 1% (N = 1)  
According to you how often should a water storage container be cleaned? 
 Every day 53% (N = 37)  
 Every week 29% (N = 20) 10% (N = 1) 
 Every month 1% (N = 1) 10% (N = 1) 
 Every 3 months 4% (N = 3) 70% (N = 7) 
 Never 4% (N = 3)  
 Don't know 3% (N = 2)  
What is the best practice to drink water? 
 With a clean container 71% (N = 50) 100% (N = 10) 
 With a used container 21% (N = 15)  
 With hands 6% (N = 4)  
 Don't know 1% (N = 1)  
What according to you is the best practice to store drinking water? 
 Closed mouth clean container 70% (N = 49) 100% (N = 10) 
 Closed mouth container 21% (N = 15)  
 Open mouth clean container 1% (N = 1)  
 Open mouth container 7% (N = 5)  
Do you know any person who has suffered due to use of unsafe drinking water? Select all that apply 
 Family member 10% (N = 7)  
 Relatives 3% (N = 2) 20% (N = 2) 
 Neighbors 13% (N = 9) 20% (N = 2) 
 Friends 6% (N = 4)  
 Don't know 23% (N = 16)  
 None 41% (N = 29) 60% (N = 6) 
 Family member, friends 3% (N = 2)  
 Family member, relatives, neighbors, friends, classmate/colleague 1% (N = 1)  
How is the drinking water facility at the school? 
 Poor 21% (N = 15) 10% (N = 1) 
 Good 37% (N = 26)  
 Satisfactory 36% (N = 25) 90% (N = 9) 
 Very good 4% (N = 3)  
 Excellent 1% (N = 1)  
Is the water facility in the school adequate to meet daily drinking requirements? 
 Yes 58.6% (N = 41) 90% (N = 9) 
 No 41.4% (N = 29) 10% (N = 1) 
How are the toilet facilities on the schools premises? 
 Poor 34% (N = 24)  
 Good 30% (N = 21)  
 Satisfactory 29% (N = 20) 100% (N = 10) 
 Very good 3% (N = 2)  
 No toilet 3% (N = 2)  
 Not clean 1% (N = 1)  
Are there any diarrheal episodes occurring in the school to your knowledge? 
 Yes 23% (N = 16) 10% (N = 1) 
 No 40% (N = 28) 90% (N = 9) 
 Don't know 37% (N = 26)  
What is the average no. of students taking leave in a month from class? Mean = 6, SD = 3  
Variables Students Staff 
What do you think about drinking water in your school? 
  Safe for drinking 61% (N = 43) 100% (N = 10) 
  Unsafe for drinking 13% (N = 9)  
  Can't say 26% (N = 18)  
Do you think quality of water can affect health? 
 Yes 61.4% (N = 43)  
 No 31.4% (N = 22) 60% (N = 6) 
 I don't know 7.2% (N = 5) 40% (N = 4) 
What should be done to clean water? 
 Use water purifying systems 34% (N = 24) 10% (N = 1) 
 Boil 56% (N = 39) 20% (N = 2) 
 Use cloth filter 33% (N = 23) 10% (N = 1) 
 Use chlorine 10% (N = 7) 60% (N = 6) 
 Do nothing 3% (N = 2)  
 I don't know 1% (N = 1)  
According to you how often should a water storage container be cleaned? 
 Every day 53% (N = 37)  
 Every week 29% (N = 20) 10% (N = 1) 
 Every month 1% (N = 1) 10% (N = 1) 
 Every 3 months 4% (N = 3) 70% (N = 7) 
 Never 4% (N = 3)  
 Don't know 3% (N = 2)  
What is the best practice to drink water? 
 With a clean container 71% (N = 50) 100% (N = 10) 
 With a used container 21% (N = 15)  
 With hands 6% (N = 4)  
 Don't know 1% (N = 1)  
What according to you is the best practice to store drinking water? 
 Closed mouth clean container 70% (N = 49) 100% (N = 10) 
 Closed mouth container 21% (N = 15)  
 Open mouth clean container 1% (N = 1)  
 Open mouth container 7% (N = 5)  
Do you know any person who has suffered due to use of unsafe drinking water? Select all that apply 
 Family member 10% (N = 7)  
 Relatives 3% (N = 2) 20% (N = 2) 
 Neighbors 13% (N = 9) 20% (N = 2) 
 Friends 6% (N = 4)  
 Don't know 23% (N = 16)  
 None 41% (N = 29) 60% (N = 6) 
 Family member, friends 3% (N = 2)  
 Family member, relatives, neighbors, friends, classmate/colleague 1% (N = 1)  
How is the drinking water facility at the school? 
 Poor 21% (N = 15) 10% (N = 1) 
 Good 37% (N = 26)  
 Satisfactory 36% (N = 25) 90% (N = 9) 
 Very good 4% (N = 3)  
 Excellent 1% (N = 1)  
Is the water facility in the school adequate to meet daily drinking requirements? 
 Yes 58.6% (N = 41) 90% (N = 9) 
 No 41.4% (N = 29) 10% (N = 1) 
How are the toilet facilities on the schools premises? 
 Poor 34% (N = 24)  
 Good 30% (N = 21)  
 Satisfactory 29% (N = 20) 100% (N = 10) 
 Very good 3% (N = 2)  
 No toilet 3% (N = 2)  
 Not clean 1% (N = 1)  
Are there any diarrheal episodes occurring in the school to your knowledge? 
 Yes 23% (N = 16) 10% (N = 1) 
 No 40% (N = 28) 90% (N = 9) 
 Don't know 37% (N = 26)  
What is the average no. of students taking leave in a month from class? Mean = 6, SD = 3  

Twenty-nine percent (N = 16) of the students reported occurrence of diarrheal episodes in the school due to unsafe drinking water (Figure 1). Student participants reported vomiting, fever, coughs and colds, throat pain/infection, and stomach pain as the most common symptoms due to unsafe drinking water.

Figure 1

Common diseases due to unsafe drinking water.

Figure 1

Common diseases due to unsafe drinking water.

WASH practices

The majority (77%; N = 54) of the student participants and all (100%; N = 10) of the school staff participants drank directly from tap water (Table 4). The majority (80%; N = 56) of the student participants practiced hand washing before eating food, 63% (N = 44) after eating food and 40% (N = 28) whenever their hands were dirty, whereas only 30% (N = 3) of staff participants practiced hand washing before eating food. However, very few student (30%; N = 21) and staff (10%; N = 1) participants practiced hand washing after defecation. The majority of participants (students: 84%; N = 59 and school staff 80%; N = 8) responded that hand washing prevents infections/remove germs. Eighty percent (N = 56) of student participants and 100% (N = 10) of staff participants used water and soap for washing hands. Ninety-one percent (N = 64) of student and 100% (N = 10) of staff participants brought drinking water from home. All (100%; N = 10) the staff participants said that water quality testing is done but 74% (N = 52) of student participants responded no to any water quality testing in the school but no participant knew about the last water testing date. According to 80% (N = 8) of staff and 23% (N = 16) of student participants, water storage containers were cleaned on a quarterly basis, while 29% (N = 20) of students said cleaning of containers was done on a weekly basis. Seventy-nine percent (N = 55) of the students and 80% (N = 8) of school staff did not know about water being treated before being provided for drinking. More than half (53%; N = 37) of the students said utensils used for drinking water were clean but the majority (80%; N = 8) of the staff did not agree. Most of the participants said water in the toilets was available through the taps but still some (36%; N = 25 students and 10%; N = 1 staff) participants said water was available only sometimes (Table 4). The majority (80%; N = 8) of the staff said soap was provided outside the toilet for washing hands, whereas 97% (N = 67) of the students responded no to this. Seventy-seven percent (N = 54) of the students and 100% (N = 10) of the staff participants said the school provided education on water and sanitation hygiene.

Table 4

Practice of water and sanitation hygiene

Variables Students Staff 
From where do you drink water in your school? 
 Bring own water from home 20% (N = 14)  
 Directly from tap 77% (N = 54) 100% (N = 10) 
 Both 3% (N = 2)  
When do you wash your hands? 
 Whenever dirty 40% (N = 28) 50% (N = 5) 
 Before eating 81% (N = 57) 30% (N = 3) 
 After eating 63% (N = 44) 50% (N = 5) 
 After defecation 30% (N = 21) 10% (N = 1) 
Reasons for washing hands (or) why do you wash hands? 
 Prevent infection/remove germs 84% (N = 59) 80% (N = 8) 
 Feels clean 30% (N = 21) 20% (N = 2) 
 Appears good 9% (N = 6)  
What do you wash your hands with? 
 Water and soap 80% (N = 56) 100% (N = 10) 
 Water only 19% (N = 13)  
Do you bring water from home to drink? 
 Yes 91% (N = 64) 100% (N = 10) 
 No 9% (N = 6)  
If yes, then ask frequency? 
 Always 66% (N = 46) 10% (N = 1) 
 Sometimes 26% (N = 18) 90% (N = 9) 
 Daily 1% (N = 1)  
Is the drinking water tested for quality in the school? 
 Yes 26% (N = 18) 100% (N = 10) 
 No 74% (N = 52)  
When was the last time quality of water was tested in the school? 
 Don't know 100% (N = 70) 100% (N = 10) 
How frequently are the water storage containers cleaned thoroughly? 
 Before fetching fresh water 1% (N = 1)  
 Within a week 29% (N = 28) 20% (N = 2) 
 Every 2 weeks 1% (N = 1)  
 Every month 17% (N = 12)  
 Every 3 months 23% (N = 16) 80% (N = 8) 
 Never 10% (N = 7)  
 When it is dirty 6% (N = 4)  
Is the water treated before being available for drinking? 
 Yes 6% (N = 4)  
 No 11% (N = 8) 10% (N = 1) 
 I don't know 79% (N = 55) 80% (N = 8) 
Are clean utensils available for drinking water? 
 Yes 53% (N = 37) 10% (N = 1) 
 No 44% (N = 31) 80% (N = 8) 
Is drinking water available in every block or floor of school? 
 No 100% (N = 70) 100% (N = 10) 
What is the source of water in the toilets of the schools? 
 In Buckets 24.3% (N = 17) 30% (N = 3) 
 Tap 71.4% (N = 50) 70% (N = 7) 
Is water available in the toilets? 
 Always 53% (N = 37) 70% (N = 7) 
 Sometimes 36% (N = 25) 30% (N = 3) 
 Never 10% (N = 7)  
Is soap or another facility provided outside the toilets for washing hands? 
 Never 97% (N = 68) 20% (N = 2) 
 Sometimes 3% (N = 2) 80% (N = 8) 
Do staff and children share common toilets? 
 No 100% (N = 70) 100% (N = 10) 
Does the school provide education on water and sanitation hygiene? 
 Yes 77% (N = 54) 100% (N = 10) 
 No 23% (N = 16)  
Variables Students Staff 
From where do you drink water in your school? 
 Bring own water from home 20% (N = 14)  
 Directly from tap 77% (N = 54) 100% (N = 10) 
 Both 3% (N = 2)  
When do you wash your hands? 
 Whenever dirty 40% (N = 28) 50% (N = 5) 
 Before eating 81% (N = 57) 30% (N = 3) 
 After eating 63% (N = 44) 50% (N = 5) 
 After defecation 30% (N = 21) 10% (N = 1) 
Reasons for washing hands (or) why do you wash hands? 
 Prevent infection/remove germs 84% (N = 59) 80% (N = 8) 
 Feels clean 30% (N = 21) 20% (N = 2) 
 Appears good 9% (N = 6)  
What do you wash your hands with? 
 Water and soap 80% (N = 56) 100% (N = 10) 
 Water only 19% (N = 13)  
Do you bring water from home to drink? 
 Yes 91% (N = 64) 100% (N = 10) 
 No 9% (N = 6)  
If yes, then ask frequency? 
 Always 66% (N = 46) 10% (N = 1) 
 Sometimes 26% (N = 18) 90% (N = 9) 
 Daily 1% (N = 1)  
Is the drinking water tested for quality in the school? 
 Yes 26% (N = 18) 100% (N = 10) 
 No 74% (N = 52)  
When was the last time quality of water was tested in the school? 
 Don't know 100% (N = 70) 100% (N = 10) 
How frequently are the water storage containers cleaned thoroughly? 
 Before fetching fresh water 1% (N = 1)  
 Within a week 29% (N = 28) 20% (N = 2) 
 Every 2 weeks 1% (N = 1)  
 Every month 17% (N = 12)  
 Every 3 months 23% (N = 16) 80% (N = 8) 
 Never 10% (N = 7)  
 When it is dirty 6% (N = 4)  
Is the water treated before being available for drinking? 
 Yes 6% (N = 4)  
 No 11% (N = 8) 10% (N = 1) 
 I don't know 79% (N = 55) 80% (N = 8) 
Are clean utensils available for drinking water? 
 Yes 53% (N = 37) 10% (N = 1) 
 No 44% (N = 31) 80% (N = 8) 
Is drinking water available in every block or floor of school? 
 No 100% (N = 70) 100% (N = 10) 
What is the source of water in the toilets of the schools? 
 In Buckets 24.3% (N = 17) 30% (N = 3) 
 Tap 71.4% (N = 50) 70% (N = 7) 
Is water available in the toilets? 
 Always 53% (N = 37) 70% (N = 7) 
 Sometimes 36% (N = 25) 30% (N = 3) 
 Never 10% (N = 7)  
Is soap or another facility provided outside the toilets for washing hands? 
 Never 97% (N = 68) 20% (N = 2) 
 Sometimes 3% (N = 2) 80% (N = 8) 
Do staff and children share common toilets? 
 No 100% (N = 70) 100% (N = 10) 
Does the school provide education on water and sanitation hygiene? 
 Yes 77% (N = 54) 100% (N = 10) 
 No 23% (N = 16)  

DISCUSSION

The Indian legislation right of children to free and compulsory education Act (2009) requires drinking water and sanitation facilities at the school level (DISE 2012). Ninety-three percent of schools in India now have access to drinking water (DISE 2012). Provision of drinking water and sanitation facilities does not ensure a child's health, but functionality and hygiene are important aspects of it.

In this pilot cross-sectional study, an attempt was made to understand the existing knowledge, attitude and practice behaviors among school children living in rural settings in Chennai, India. The results of our study showed that the most common source of drinking water supply in the schools was groundwater with no water treatment facilities. The majority of the students (87%, N = 61) agreed that no water testing was done in the school. The results showed that school children and the school staff had separate drinking points with taps from source of supply. The school had a total of 8 toilets with separate facilities for girls, boys and the school staff. There were significant differences in the perceptions of the children and the school staff about receiving water, sanitation and hygiene education (57%, N = 40 versus 100% (N = 10), and 91% (N = 64) of the school children agreed that they were taught about hand-washing practices. Prior studies have also shown that school water and sanitation hygiene education promote safe environments at home and in the community. Healthy children in healthy environments learn more effectively (UKAID 2013).

The results also showed that 61% (N = 43) of the school children perceived that the water they drink in the schools is safe. There were differences in the water treatment methods that were reported by the school children and the school staff. Boiling of water was reported as a preferred method to clean drinking water by the school children compared to the school staff who reported water chlorination as the preferred method. Prior studies also showed that cheap household methods like boiling, chlorination and filtration can improve the quality of drinking water and prevent disease (UNICEF 2012). Sixty-one percent (N = 43) of the school children perceived that quality of water can affect health. Diarrhea, cholera and typhoid were the major health problems identified due to poor drinking water quality. These results were similar to the school staff that also reported these problems. The most common symptoms associated with poor drinking water quality included vomiting, fever and colds. Diarrheal episodes were also reported by the student participants to be occurring in the school. Prior studies have also revealed the presence of intestinal parasitic infection among school-going children in rural India with poor water and sanitation hygiene practices (Dongre et al. 2008). This pilot study showed that an average of six students took leave from school every month. Previous studies have shown an increase in absenteeism from school due to improper sanitation facilities in the developing world (Jasper et al. 2012). Very few school children reported that the drinking water quality would be poor if there was a change in the color, smell and taste of the water. More than half of the school children reported water facilities in the school to be adequate to meet daily drinking requirements compared to 34% reporting toilet facilities on the school premises to be poor.

Our study had certain limitations. First, it included only a single school. Second, it was limited to one geographical location so its results cannot be generalized. Also, the study did not include water quality testing of water-tanks, drinking points and utensils used by school children and staff. Future studies should be carried out to compare the hygiene facilities along with water quality testing both in the school and home settings. Further gender-specific needs should also be examined to specifically address the needs of the girl students.

CONCLUSION

The results of the study showed a need for a multifaceted intervention that will facilitate adequate water and sanitation hygiene practices among the school children through availability of proper sanitation infrastructure, and family-centered education. Adequate measures should be taken for testing water quality at the drinking points and at the water-tank on a regular basis, and for recording the results. The children and teachers should be taught how to interpret water quality records and thereafter have a plan of action for purification using chlorination or similar.

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