1. Why school hygiene and sanitation: the health perspective
About 400 million school-age children are infected by roundworm, whipworm, hookworm, schistosomiasis and other flukes and/or guinea worm, often with multiple species infections. These parasites consume nutrients from children they infect. In doing so they bring about or aggravate malnutrition and retard children's physical development. This can lead to stunting, underweight and anemia (iron deficiency anemia, IDA).
Recent studies strongly suggests that school-age children suffer from higher levels of stunting than previously acknowledged. Stunting is increasingly being used as an indicator of population well being and indicator for poverty. Estimates from the WHO global database are that 53% of school-aged children in developing countries are suffering from IDA. When levels of anemia exceed 40% it is defined as a public health problem requiring the provision of iron supplements, a health service included in the FRESH framework together with deworming.
Morbidity and mortality associated with various water and sanitation related diseases
| Disease Type
|| Morbidity (no. of cases each year)
||Mortality (deaths each year)
||Population at risk|
|| <4,000 million
|| 2.5 million
|| <2,000 million|
| Amoebic Dysentery
|| 145,000 (1996 data)
|| 10,000 (1996 data)
|| 250 million
|| 151 million
|| 43.5 million
| Guinea Worm
|| 100 million|
|| 600 million (6 million blind)
|| 500 million|
|| 600 million|
Source: World Health Report, 1998
- Helminth particularly hookworm infection have been shown to cause iron deficiency anemia (IDA), reduce growth and may negatively affect cognition. (Stoltzfus et al, 1997)
- It is estimated that 210 million schoolchildren suffer from IDA (Del Rosso and Marek, 1996).
- There is substantial evidence that IDA in children is associated with decreased physical and mental development and impaired immune function.
- Inadequate water and sanitation facilities can contribute to high rates of transmission of helminth infections, that in turn contribute to iron deficiency anemia.
Figure 1. shows that the highest rate of roundworm and whipworm infections are often demonstrated in groups of 5-9 and 10-14 years old.
Figure 1. Worm infection by age (adapted from Bundy, 1988)
Global prevalence and number of cases of intestinal helminth infection in school-age children are estimated at: Roundworm 35% (320 million); Whipworm 25% (233 million); Hookworm 26% (239 million). (Partnership for Child Development, 1997.)
As most of the worm infections are preventable, the emphasis should be on key interventions to break the transmission of these diseases:
- The safe, efficient and hygienic disposal of faeces, particularly child faeces.
- The safe, efficient and hygienic management of water from extraction, through transport and storage to use (particularly for drinking and hand-washing).
- The regular and effective use of water (with a scouring agent like soap or ash) for hand washing after contact with stools (Curtis, 1998).
Multiple, coordinated strategies produce a greater effect than individual strategies, but these strategies need to be selective and targeted. While treatment of parasitic infections may have an immediate short term impact, a program will only show a sustainable effect when combined with training of teachers and administrators, classroom education and the provision of sanitary facilities all included in the FRESH framework of action.
2. Why school hygiene and sanitation: the learning perspective
As numerous studies show, education and health are inseparable: stunting, nutritional deficiencies, diarrhea and helminth infections affect school participation and learning. It is well known that stunted children enroll late into school and probably are less likely to complete their schooling with long term consequences for educational performance, outcome and productivity. Importantly, many of these issues can be addressed effectively through health, hygiene and nutrition policies and programs for students and staff.
Helminth reduction programmes in schools can have a significant impact on health and learning among school children. De-worming of school-age children can improve both growth and educational achievement, especially for the children most heavily infected.
Data from studies show that the prevalence of stunting increased with age showing a higher proportion of stunted school-age children. (Partnership for Child Development, 1998).
Studies have shown that linear growth continues beyond the normal puberty growth period. This suggests that school based programmes aimed at improving health and nutrition status may have the potential to bring about catch-up growth in stunted school age children. (Stoltzfus et al. 1997, 1998)
Children with heavy worm burdens are likely to be absent from school for a greater proportion of the time than those who are lightly infected or free from worms (Figure 2).
Figure 2. School Absenteeism and helminth infection
Worm infection has also been shown to influence children's cognitive ability (see Drake et al, 2000) and school attendence (e.g. Simeon et al., 1995).
3. Why school hygiene and sanitation: the gender perspective
Lack of facilities and poor hygiene affect both girls and boys, although poor sanitation conditions at schools have a stronger negative impact on girls. All girls should have access to safe, clean, separate and private sanitation facilities in their schools. If there are no latrines and hand-washing facilities at school or if they are in a poor state of repair, then many children would rather not attend than use the alternatives. In particular girls who are old enough to menstruate need to have adequate facilities at school and normally separate from those of boys, this is strongly supported by FRESH. If they don’t they may miss school that week and find it hard to catch up, which makes them more likely to drop out of school altogether.
Many children, again mainly girls, miss out on time at school because they are having to walk long distances in order to fetch water. Also in schools, when the schoolteacher sends children to fetch water, it is predominantly girls who are sent.
Lessons learned from a DPHE-UNICEF study in 1994 and 1998 in Bangladesh showed that provision of water and sanitation facilities in schools increased girls’ attendance by 15%. Interaction with family and demand for sanitation facilities at home were seen in 80% of children where those practices were acquired at school.
In addition to the obvious health benefits and time savings (particularly affecting young school-age girls), provision of safe water and sanitation facilities can also have an influence on school enrolment and attendance. The lack of adequate, separate sanitary facilities in schools is one of the main factors preventing girls from attending school, particularly when menstruating. In Bangladesh, a school sanitation program increased girls' enrolment by 11%, a level that is beyond the reach of conventional educational reform (Cairncross, 1998).
When other family members become sick (often due to sanitation related diseases), girls are more likely to be kept home to help. This can lead to reduced school attendance by girls and can result in an increase in drop-out rates. This situation will become even more critical in communities hard hit by the HIV/AIDS pandemic.
4. Why school hygiene and sanitation: the child's perspective
Children spend long hours in schools. The school environment will partly determine these children’s health and well–being by providing a healthy or unhealthy environment. Compared to adults, children are often more receptive to new ideas and can more easily change their behavior and/or develop new long-term behaviors as a result of increased knowledge and facilitated practices.
Depending on the culture, children and youth, may question existing practices in the household and become agents of change within their families and communities. Teachers as professionals and influential individuals, supported by the school management, can play an important role in the development of pupils through training and providing a role model in the communities.
Life skills training (LST) as promoted by FRESH and used in water and sanitation education can help children make informed decisions and avoid risky situations and behaviors and give them opportunity to practice these skills. They are more effective than traditional teaching methods in influencing behavior rather than just imparting knowledge. These skills are best acquired through learner-centered, participatory, experimental programmes (e.g. WHO, 1996)
Children are future role models and parents. What they learn at school is likely to be passed on to their peers and to their own children. It is obvious that all sanitation facilities and educational programs should be adapted to the different physical and cultural needs of girls and boys at different ages, key aspects enshrined in the concept of child friendly schools.
5. School sanitation facilities are not enough
Although there is an urgent need for speeding up the installment of appropriate facilities, school sanitation is not only about building child-friendly facilities. Experience shows clearly that mere provision of services, be it within schools or at household level, will not be sustainable. Facilities need to be maintained, and in order to be maintained there must be a recognized need and demand for water as well as sanitation at schools. To improve the sanitation environment of schools, and to ensure benefits from safe and clean facilities, behavioral change is needed, leading to a proper use of the facilities as well as to organized maintenance of the facilities and to sanitation-related behaviors such as hand-washing.
Government officials from 6 different countries in Sub-Saharan Africa gave situation reports on water and sanitation at home and in schools at the Water and Sanitation workshop in October 2000 in Burkina Faso. For most of the countries the assessments showed lower coverage in schools of water and latrines compared to the general population and low state of usage and maintenance. In Cote d’Ivoire, for example, 62% in rural areas had water and 40 % in the capital Abidjan had sanitation. In schools only 30% has water and 32 % latrines. According to a survey in the Yopougon area, Cote d’Ivoire, 62% of WCs do not work and there are about one WC/latrine per 381 students (suggested 1/40 girls and 1/80 boys) and one urinoire per 892 students (suggested 1/50).
Schools are an integral part of a community. Involvement of the local community in school sanitation and hygiene activities increases the effectiveness of the programs. It also promotes the sense of ownership within communities that is needed to sustain the school systems for operation and maintenance, particularly important in the absence of effective local government to provide such services. Although school sanitation and hygiene promotion can bring health benefits for the children and their family members who may improve their sanitation, it is clear that sanitation is a public good and that sanitation improvement has much greater benefit when it is achieved by a whole community. Experience shows that children can act as potential agents of change within their homes and communities through their knowledge and use of sanitation and hygiene practice learned at school.
A recent review of 144 different interventions demonstrated the impact on morbidity of general water, sanitation and hygienic interventions:
- 36% median reduction of diarrhea from the safe disposal of faeces
- 35% median reduction of diarrhea from hand-washing with soap after contact with stools
- 20% median reduction in diarrhea from protection of water from faecal contamination
- 26% median reduction in diarrhea from the integration of hygiene education or promotion in water projects (Esrey et al., 1990)
However, without mobilization and motivation of the community as a whole, the impact of a school sanitation and hygiene promotion program may remain limited.
6. Targets for the future
The shared world vision for hygiene sanitation and water supply, based on the recognition of hygienic conditions and adequate access to safe water and sanitation services as fundamental rights, includes school sanitation and hygiene education targets. The suggested school sanitation and hygiene education targets for 2015 are:
- 80% of primary school children educated about hygiene
- all schools equipped with facilities for sanitation and hand-washing
These targets are most effectively implemented within the context of the FRESH Partnership, where provision of safe water and sanitation for schools is positioned as one of the core FRESH activities.
Bundy, D.A.P. (1988). Population ecology of intestinal helminth infections in human communities. Philosophical Transactions of the Royal Society, London (B). 331: 405-420.
Cairncross, S. (1998). Why promote sanitation and hygiene? (from UNICEF workshop on environmental sanitation – unpublished).
Cairncross, S. et al. (1998). The public and domestic domains in the transmission of disease. Tropical Medicine and International Health. 1: 27-34.
Curtis, V. (1998) Hygienic, healthy and happy: A manual for setting up hygiene promotion programmes. New York : UNICEF.
Del Rosso. J.M. and Marek, T. (1996). Class Action. Improving School Performance in the Developing World through Better Health and Nutrition, World Bank
Drake, L.J., Jukes, M.C.H., Sternberg, R.J. & Bundy, D.A.P (2000). Geohelminth infections (Ascariasis, Trichuriasis and Hookworm): cognitive and developmental impacts. Seminars in Pediatric Infectious Diseases. 11: 245-251.
Esrey,S. et al. (1990) Health benefits from improvements in water supply and sanitation: survey and analysis of the literature on selected diseases (WASH technical report no. 66)
Hubley, J. (1998) School health promotion in developing countries.
Nokes, C., Grantham-McGregor, S.M., Sawyer, A.W. (1992). Moderate to heavy infections of Trichuris trichiura affect cognitive function in Jamaican school children. Parasitology, 104: 539-547.
Nokes, C. & Bundy, D.A.P. (1993). Compliance and absenteeism in schoolchildren: implications for helminth control. Transactions of the Royal Society of Tropical Medicine and Hygiene, 87: 148-152.
Partnership for Child Development (1997). This wormy world: Fifty years on. Parasitology Today, November 1997 (poster).
Partnership for Child Development (1998). The anthropometric status of schoolchildren in five countries in the Partnership for Child Development. Proceedings of the Nutrition Society, 57: 149-158.
What’s new in the health and nutrition of the school-age child and in school health and nutrition programmes? PCD, Carmel Dolan. Paper prepared for ACC/SCN meeting April 2000.
Simeon, D.T., Grantham-McGregor, S.M., Callender, J.E. & Wong, M.S. (1995). Treatment of Trichuris trichiura infections improves growth, spelling scores and school attendance in some children. Journal of Nutrition, 125: 1875-1883.
Stoltzfus, R.J. et al. (1997a). Linear growth retardation in Zanzibari school children. Journal of Nutrition 127, 1099-1105.
Stoltzfus, R.J. et al. (1997b) School based deworming programmes yields small improvement in growth of Zanzibar school children after one year. Journal of Nutrition 127: 2187-2193.
Stoltzfus, R.J. et al. (1998). Effects of the Zanzibar school based deworming program on iron status of children. American journal of Clinical Nutrition 68: 179-186.
WHO (1996). Strengthening Interventions to Reduce Helminth Infections: An Entry Point for the Development of Health-Promoting Schools. WHO/HPR/HEP/96.10.
WHO information Fact Sheet Nr 112, November 1996
Workshop Report. UNICEF/IRC Global Workshop on SSHE. Delft, 11-18 March 2000
top of page