Water, sanitation, and hygiene facilities: enabling or impeding handwashing? An assessment of a primary school infrastructure in Palwal, India

Hand washing with soap (HWWS) at critical moments has been recognized as a simple, cost-effective protection against communicable diseases (Centre for Disease Control and Prevention 2022). Good hand hygiene has been a recommended public health response to break the chain of infection, such as during the 2009 influenza epidemic (Liu et al. 2016) or more recently, the 2020 COVID-19 pandemic, where frequent and proper HWWS was one of the key prescribed preventive measures (World Health Organization 2020). HWWS is also the suggested response to protect against diarrhea, one of the leading causes of morbidity and mortality among children, especially in low-income countries (Freeman et al. 2014). It is estimated that diarrhea caused about 1.66 million deaths in 2016, more than a quarter of which were among children under the age of 5 years (Naghavi et al. 2017).

There is increasing evidence that water, sanitation, and hygiene (WASH) infrastructure when supported by school-based hygiene promotion activities plays an important role in reducing the risk of illnesses such as diarrhea and respiratory diseases among children (Freeman et al. 2012; Caruso et al. 2014). Access to adequate and functional WASH facilities is the foremost pre-requisite to practicing good hygiene habits. The WHO/UNICEF Joint Monitoring Program (JMP) for WASH in schools evaluates facilities through the lens of availability, accessibility, acceptability and quality (WHO 2016). However, schools in many developing and low-income countries lack basic WASH facilities. In 2016, 49% of schools in the least developed countries did not have any hygiene service, 37% did not have a drinking water service, while only 49% of schools had basic sanitation service (WHO, UNICEF 2021). Moreover, schools in rural areas have significantly poorer coverage than those in urban areas (UNICEF 2018). In India, the Ministry of Human Resources and Development stipulates the minimum requirement for WASH facilitates in schools under the Swachh Bharat, Swachh Vidyalya (Clean India, Clean School) National Mission. This includes gender-segregated, inclusive toilets in the ratio of one unit (one toilet + three urinals) for every 40 students, menstrual hygiene management facilities; daily provision of child-friendly, sustainable, safe drinking water; sufficient group handwashing facilities with adequate availability of water and soap (Ministry of Human Resource & Development n.d.). However, there are not enough studies done to assess if the schools in India meet this requirement. The present study, therefore, sought to assess the quality of WASH infrastructure available to students in rural India with the assumption that students in rural areas are likely to have poor access to quality infrastructure.

The objective of the study was two-fold: (a) to review the availability and functionality of WASH infrastructure for primary school children in rural areas and (b) to assess the association between the quality of services and hand hygiene practice of students in rural Palwal.

The present study was conducted in the predominantly rural Palwal district of Haryana State in India. A list of all government primary schools across all three administrative blocks was obtained from the District Elementary Education Officer and eligible schools were identified. Eligible schools were co-educational with a minimum of 100 students enrolled for the academic year 2019–2020 and had a functional Mid-Day Meal (MDM) Program, now called the PM POSHAN Scheme. Systematic random sampling was used to select the study sample. Since there is one government primary school per village, a population-representative sample (10% of villages per block), was randomly selected. Thus, a total of 28 schools participated in the present study.

Data were collected using a self-administered survey questionnaire for students, an interview schedule for class teachers and an observation checklist to map the school WASH infrastructure. The UNICEF core WASH questions for school surveys were used to develop the observation checklist (UNICEF, WHO 2016). The WHO/UNICEF JMP for Water Supply, Sanitation and Hygiene reports WASH data at global, regional, and country levels, providing comparable estimates of progress (How we work. JMP n.d.). The JMP expanded its database to include WASH in schools in 2018 (Schools. JMP n.d.). The new JMP service ladder for global monitoring of WASH in schools grades school into four categories according to the level of WASH facilities available at the time of visit (Schools. JMP n.d.). Two additions were made to the existing JMP checklist:

• (a)

  Distance of handwashing station from toilet.

• (b)

  Height of handwashing station from the ground.

The modified checklist was also critically evaluated against the essential elements recommended under the Swachh Bharat, Swachh Vidyalaya program to account for local relevance. Along with the modified observation checklist, an assessment was made on the hand hygiene knowledge, attitude, and practice (KAP) of students through the self-administered survey questionnaire developed and pre-tested in the local language. Class teachers were interviewed to understand the student's behavior as well as challenges faced at the school level with respect to the available facilities.

Pre-testing was done in five schools in another district with similar sociodemographic characteristics and analyzed using Cronbach's Alpha where a reliability quotient of 0.71 was obtained. The results of hand hygiene KAP are published elsewhere (Gupta & Anand 2022). Each school was visited once before lunchtime and WASH facilities were inspected against the developed observation checklist. Pictures were clicked wherever principals gave consent. This was a cross-sectional, mixed-method study.

Collected data were sorted and checked for completeness at the school level. Data were collated and organized in Microsoft Excel (version 16.16.27). SPSS software (version 21.0) was used for data analysis. The WASH facilities were classified according to the JMP service ladder as advanced, basic, limited, or no service (UNICEF 2018). Analysis was done using descriptive statistics. Test of significance Chi-square (χ²) was done for further analysis wherever possible.

The Institutional Ethics Committee, Lady Irwin College, University of Delhi gave ethical clearance for the study (FOS-I/114/2019/8498). Written informed consent was taken from school principals, class teachers, and parents. Written assent was obtained from each of the respondents. Students were free to decline participation at any point during data collection.

All the schools in the study sample had provision for sufficient, clean drinking water for students (Table 1). Of the 28 schools, 93% had basic service levels, while 7% had advanced service levels. Of the schools with basic service, 62% had access to piped water which is classified as an improved source under the new JMP service ladder and water was available at the school at the time of visit. Nearly 31% of schools had upgraded their drinking water facility with the support of a donor agency working in the region. About 39% of the schools had protected boreholes with a functional handpump as the source of drinking water. The schools that were found to have advanced levels of service had provisions for water filters and coolers, ensuring continued access to safe drinking water. Additionally, all the schools had a raised platform at the water station to facilitate access for younger and shorter students. Class teacher interviews revealed that some of the students came from homes with unreliable drinking water supplies, especially during the summer months. Since the school ensured a year-round supply of drinking water, children would often bring empty bottles and fill them up on their way back.

The hygiene condition of the drinking water station varied from very clean and hygienic with piped exit for running water at one end to stagnating water and algae at the other. These findings are unlike the findings reported by Cronk et al. (2021) in their school WASH study from 14 low- and middle-income countries, where 24% of the rural schools had no drinking water service. Another study by Antwi-Agyei et al. (2017) in Tanzania also found only 53% of schools have a year-round supply of drinking water. Ahmed et al. (2020) also found that 7% of sampled schools in Pakistan had advanced service levels, 57.4% had basic, 19.8% had limited, and 16% of schools had no service at all. Access to ample, safe drinking water is a basic necessity for students and efforts should be made to provide for the same. The central Department of School Education and Literacy data also reports that 99.6% of all government schools in the state of Haryana have drinking water facilities within the school premises (Ministry of Education 2021-22).

All the schools in the study sample provided gender-segregated, private, functional, and safe toilets (Table 2). About 57% of the schools were found to have basic sanitation service levels with improved facilities that were single-sex and usable at the time of visits. Only 11% of schools had advanced service levels with separate toilets for differently abled students. Nearly 32% of schools had limited sanitation service levels, as the toilets were dirty and unusable at the time of the visit. The toilets were constructed as a separate unit from the rest of the school building in all the schools. The boys' toilet complex had separate urinals along with flush and pour-flush toilets. The toilets for both boys and girls had provision for anal cleaning with water connection, bucket, and flush/pour-flush facility. While the connection was there, there was no water available in seven schools and another two had unclean, unusable toilets at the time of the visit. The Ministry of Education (2021-22) data reports that about 98% of government schools have functional gender-segregated toilets. The data, however, does not suggest the usability of toilets due to cleanliness and maintenance issues as found in the present study. Interviews with class teachers also suggested that maintenance of toilets was a big concern as it was difficult to retain a housekeeping staff. Some teachers also said that there are budgetary concerns in government schools, unlike the private schools which can spend more on their staff and, therefore, have better facility management (refer the following quote).

The majority of teachers felt that their school's hygiene and sanitation infrastructure was good as per government school standards, and they stressed that it should not be compared to private schools which have more resources. Typically, private schools have been found to provide better WASH infrastructure than government schools (Acheampong et al. 2019; Ahmed et al. 2023).

Only 43% of schools in the present study met the minimum student-to-toilet ratio of one unit per 40 students as per the Swachh Vidyalaya guidelines. There is massive scope for improving the number of toilets as well as making provision for their maintenance. Overall, the condition of toilets in the present study could be improved in terms of both usability and cleanliness. It is important that the schools maintain clean, usable and inviting toilets because children's experience and perception of the school facilities affect their attitude and hand hygiene behaviors (Lundblad & Hellström 2005). A study by Reeves et al. (2012) in New Zealand also found the toilets to have limited functionality simply because they were not maintained, thus preventing children from having access to high-quality hygiene facilities. Functional toilet and hand washing facilities are important to minimize the risk of infection in children, especially in developing countries where the home environment may also be limited (Adams et al. 2009).

According to the central Department of School Education data, 99.6% of government schools in Haryana have a hand washing facility (Ministry of Education 2021-22) (Table 3). The present study, however, made some unique observations on the hygiene aspect in schools. While wash basins were provided within the toilet complex as part of the construction design, most of them were found to be non-functional, with broken taps and no water connection. All the schools, however, had a separate designated area for washing hands which was close to the toilet building and away from the drinking water source. This handwashing station was used for all handwashing purposes – after toilet, before eating, after playing. However, self-reported data on hand hygiene practice indicated that this may be a faulty approach as 39.1% of students reportedly did not wash their hands after using the toilet because they found the handwashing station to be too far. So even when the handwashing stations were in the vicinity of the toilet complex, they were still perceived to be far by the students. The placement of a handwashing station has the potential to act as a visual cue or reminder to prompt the action. A study by Hulland et al. (2013) at the household level recommends the placement of handwashing stations at the place of interjection to trigger the action such as inside the kitchen to promote the habit of handwashing before cooking.

Of the 28 schools in the study sample, 64% had limited hygiene service levels with water but no soap available at the time of visit. The soap was given to students for handwashing before the MDM only, which meant that students were not able to practice HWWS after using toilets, making them vulnerable to illness. About 29% of schools had basic handwashing facilities with both soap and water available at the time of visit. Only 7% of schools had advanced hygiene service levels with functional group handwashing facilities and soap available. A study by Wada & Oloruntoba (2021) in Lagos, Nigeria found that 60% of the samples provided limited service and 40% provided no service. Class teachers’ interviews provided some distinct qualitative insights into the hygiene aspects of students. They stated that the reason soap was not placed at the handwashing station was because students would often pocket the soap and take it home with them. Others said that even when the soap is provided it is not kept properly and could often be found thrown about on the floor, dirty, and practically unusable.

Theft of soap and other handwashing supplies has been found as a barrier to the regular practice of handwashing by previous studies as well (Saboori et al. 2010; Parkinson et al. 2018). Replacing these supplies regularly is an additional economic burden on the schools. The class teachers rationalized giving soap only before eating MDM as the most plausible solution to the problem.

The mean height of the handwashing station (excluding handpump) was 75.2 ± 7.3 cm which were found to be comfortable for primary school children. Additionally, all the schools had a raised platform for children to stand on while washing their hands, thus improving accessibility. There was no significant association found between the height of the wash basin and children's hand hygiene KAP score. The average distance of the handwashing station from the toilet was 45 ± 40.36 m (range 5–100 m). The findings are similar to the study by Wada et al. (2020) in Lagos, where the mean distance of the toilet facilities from classrooms in public schools was 42.70 ±30.52 m. Their study reports boys' toilet facilities to be nearer to the classroom than girls' toilets both for public and private schools. This study did not find such gender-based distinction in the sampled schools.

The present study finds universal coverage of WASH facilities in the sampled schools although with varying degrees of access and quality across the different dimensions of WASH. All the schools in the study sample had provision for round-the-year supply of sufficient, clean drinking water. These findings correspond with the central data which reports that 99.3% of all government schools in Haryana have a functional source of drinking water (Ministry of Education 2021-22). Less than half the schools in the present study met the minimum student-to-toilet ratio as per national guidelines. While a majority of schools had the same number of toilets for boys and girls, six schools had a lesser number of female toilets, with no significant difference in enrollments for the two genders. The present study did not find any significant difference in the hand hygiene practice of girl students from schools with a lower number of toilets than those that met the national guidelines. One possible explanation for this could be the fact that the schools had a separate handwashing station independent of the toilet complex. Assessing the impact of toilet sufficiency on the frequency of use was out of the scope of the present study. The distance of the handwashing station from the toilet complex, however, did impact the hand hygiene behavior of students. The study found that the schools where handwashing stations were ≤40 m away from the toilet had significantly higher hand hygiene KAP scores (>60%, p = 0.018) than those where handwashing stations were farther away. There is potential to improve hand hygiene practices if the washbasins provided within the toilet complex are made functional and maintained with soap and water. On the handwashing front, no significant difference was found between hand hygiene KAP from schools with different hygiene service levels, suggesting that the type of handwashing station may not impact children's hand hygiene KAP. However, the number of handwashing stations was insufficient, often leading to crowding and avoidance. These findings are consistent with a study done in Nigeria (Eseoghene & Ujiro 2013), which also found the lack of enough hand washing stations and poor supplies as limiting factors to students following proper HWWS. A study by Wichaidit et al. (2019) in Kenya also reported a poor handwashing station-to-student ratio resulting in crowding and hurried handwashing. Additionally, class teachers in the present study confirmed this behavior of students. Findings from interviews reveal that students are likely to wash their hands in a hurry or incorrectly if they see too many children waiting in line after them. It is, therefore, imperative that the policy interventions focus on not just access but also the sufficiency of the service provided to impact behavior.

The second dimension that is critical for the success of the WASH strategy is the habits of the target population. Personal hygiene is a learned behavior. The act of handwashing is a really simple one, but is not practiced enough at critical moments or practiced correctly. Hygiene promotion activities that aim at behavior change should be part of any WASH program, especially during early childhood years. Previous studies have found significant knowledge-action gaps in school children's handwashing behavior (Dajaan et al. 2018; Gupta & Anand 2022). Children not only need to be aware of the importance of washing hands with soap, especially at critical moments, but they also need to have a positive attitude for them to act. Children's poor attitude toward handwashing has also been identified as a barrier to practice (Gupta & Anand 2021). Behavior change campaigns need to identify relevant barriers and motivators to bring about sustainable change at the practice level.

Scheduled handwashing has been found to be a positively enabling factor to handwash behavior (Monsma et al. 1992). Though scheduled handwashing is mandated under the MDM scheme, the present study found adherence to be an issue. Teachers are an important stakeholder in driving habit change among school children, even more so than family and peers (Sun et al. 2019). Since children spend a lot of time in school, class teachers are privy to their behavior and actions. There is merit in including teachers' perspectives in program planning from the very beginning. Additionally, parents and the community should be involved in the conversation to bring about a holistic behavior change.

It is almost impossible to delink health from education. WASH in schools is a pathway to healthier schools and healthier, better-performing children. Teaching appropriate hygiene practices needs to be an integral aspect of WASH in schools along with providing access to adequate and equitable facilities.

The present study was limited to one district only, so the results cannot be generalized to other districts. The study was done among primary schools where the mean age of children was 10.5 years. The mean age for menarche among rural women in Haryana is 14.42 years (Pathak et al. 2014). Menstrual health and hygiene management facilities were, therefore, not part of the study scope. Also, the study only focused on rural, government schools. There is potential to expand the scope and include an assessment of facilities in urban government schools and evaluate any gaps in the implementation of the Swachh Vidyalaya policy. Additionally, an evaluation of the infrastructure available in resource-rich private schools could provide a prospective pathway for improvement.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.