Reducing Waterborne Diseases in 131 Kenyan Schools

1.0: ACTIVITY PROCEEDINGS

The Three-Star Score Card, which was used for the school assessment for WASH standards at the beginning and end of the year, was distributed to the head teachers by WE REACH. The Three-Star Approach provides designs and guidelines to help schools meet the infrastructure requirements. Purposeful sampling was used to collect data. Specifically, criterion sampling was employed. This technique was used for the identification and selection of information-rich cases for the most effective use of limited resources. Criterion sampling involved identifying and selecting teachers that are especially knowledgeable about and involved with WASH in school issues at the different levels. The teachers selected for participation in the baseline survey are also to be involved in the project thus, they will be consistent information sources for tracking project progress as well as identifying changes as a result of the project.

The analysis done by WE REACH in the selected 10 schools was done by observing the WASH conditions of the schools. Data collection was carried out in the schools site with prior communication and due verbal consent from the respective head of schools, willingness from the Health Teachers and ECDE representatives was also sought before they were requested to fill the questionnaires and were allowed to enquire any clarification from the survey team. WE REACH used the Three Star Approach which was developed by UNICEF and Government of Kenya to assess and rate the schools’ WASH Standards .The three-star approach is based on the fundamental principle that expensive water, sanitation and hygiene infrastructure in schools is not a pre-condition to meeting health goals. The approach focuses on initial simple inexpensive steps that all students wash their hands with soap, have access to safe drinking water and are provided with clean, safe, gender segregated toilets at schools every day. Our findings show that most of the school WASH facilities are significantly below the minimum WASH standards, partially due to the lack of resources and partially due to failure to prioritize WASH facilities, budgets, maintenance, and operations. Most schools fall short of the Pupil Toilet Ratio (PTR) requirements for both boys (35) and girls (25) when it comes to latrines because the majority of structures are poorly placed and only receive a limited amount of use. The hand washing stations at the schools are in disrepair, some of the tanks are leaking and some schools lack water sources, thus the tanks are instead filled with cobs, empty plastic bottles, and containers.

DISCUSSION

During the Baseline Survey, 8 schools out of the 10 schools had poor water quality while two of them lacked water sauces thus the tanks are instead filled with cobs, empty plastic bottle and containers. This exposed the school children to various types of water-borne diseases such as diarrhea, typhoid, skin and oral infections such as ringworms, boils and mouth rush. Our findings show that all the 10 schools were classified as “no star schools” in Sanitation and Hygiene because the WASH facilities are significantly below the minimum WASH standards, partially due to lack of resources and partially due to failure to prioritize WASH facilities, budgets, maintenance and operations. All the schools fall short of the Pupil Toilet Ratio (PTR) requirements for both boys (35) and girls (25) when it comes to latrines because the majority of the structures are poorly placed and only receive a limited amount of use. The hand washing stations at the schools are in despair, some of the tanks are leaking, no MHM facilities in sight and also girls are not provided with enough sanitary towels during their menarche.

Since the inception of the 2023 WASH Programme by WE REACH in the 10 partner schools, Effective WASH in the schools has improved health, boost attendance and promote gender equity and equality. WE REACH has worked with schools to improve WASH through capacity building approach and risk-based tools based in an ‘Assess- Plan-Act-Monitor’ cycle. Our enabling approach has focused on what the schools can learn and be able to do themselves, rather than just supplying facilities and services. It provided the schools the opportunity to be active actors in the improvement of their WASH infrastructure and services. WE REACH has also worked throughout the year with the Ministries of Education (MOE) and Health (MOH) authorities to strengthen implementation of WASH in Schools standards and policy.

After the schools committed to the overall strategy throughout the year and started implementing the necessary changes to advance, 5 out of 10 schools moved up to One Star Schools which met important minimum standards for a healthy, hygiene-promoting school, at the end of the school year (2023) survey. Moving from the “no star” level to a One Star School is designed to require minimal financial investments. Yet, the move is a big step because it involves changing the way WASH in Schools programming is perceived by schools, communities, and decision makers in government and support agencies. 5 out of 10  Head Teachers have done decent job of encouraging WASH at the partner schools. They have used a number of initiatives to improve WASH promotion in their respective schools. These strategies include the mobilization of infrastructure, as we saw in Emakhwale, Shianderema and Mahola Primary Schools, where after receiving training on their roles and responsibilities from WE REACH at the beginning of the year, the head teachers wrote proposals to the office of the local member of parliament and successfully the proposals resulted in the construction of 6 doors exhaustible pit latrines funded by NG-CDF Mumias East. In Epanja, Maraba and Khaunga Primary Schools, members of the school health clubs took part in the cost recovery planning session with their head teachers. The pupils with the support of the school teacher health champions, developed a cost recovery plan with income generating activities such as agriculture. They have planted vegetables as a result of their planning with the intention of selling them to teachers and people of the community. They hope to make money from the sales made during the first season of their vegetable growing project so that part of the money can be used to purchase supplies for liquid soap making. During the visit to Eshisenye Primary School when the WASH Programme was starting, WE REACH observed they did not have any MHM facility prior to WE REACH’s WASH Program. However, following the training, the school decided to convert an unused restroom into an MHM facility so that girls could use it as a changing room when they are on their menses. Shibinga Primary School has provided hand washing stations with soap near toilets and near where food is prepared and consumed to help staff and students practice good hand washing habits. However, some of the head teachers had not done much to make their schools WASH friendly e.g. Isango Primary School due to transfer of the previous Teacher Health Champion and the Head Teacher hence, head teachers need to spearhead the initiative by putting in proper strategies and ensuring proper supervision is carried out at the school level. During the visits, WE REACH established that Promotion of WASH in Primary Schools by the Head Teachers was facing a number of challenges such as low funding from the government and uncooperative parents among other issues. However majority of the targeted Head Teachers had taken every available opportunity to make their schools WASH friendly.

BASELINE/END YEAR SURVERY ON WATERRELATED ILLNESSES

Safe drinking water, hand washing and hygiene are essential to reducing the diarrheal disease burden in Kenya. In January 2023, WE REACH implemented the WASH programme in 10 public primary schools in Mumias East Sub-County, Kakamega, Kenya. Two Boards of Management (BoM’s) members and Head Teachers from each of the schools were introduced to the project and sensitized on their roles under the Kenya Water Sanitation and Hygiene (WASH) legislation, Policy and Guidelines for Pre-Primary and Primary Schools. The purpose was to enable them advocate for themselves when it comes to WASH issues and build their own WASH knowledge and capability. Two teachers and Two Young Peer Persons (YYP’s) from each of the schools were also trained and educated on the issues pertaining to Water, Sanitation, and Hygiene (WASH) and thus making them peer educators within their schools; strive for behavioral change amongst the students and establish linkages between hygiene practices, poor sanitation, polluted water sources and disease and encouraging them to create a multiplier effect and enhancing learning of students on key issues of WASH. The schools were provided training and education materials, and were instructed to form School Health Clubs with students of all grades as a means of enhancing WASH in schools and even in neighbouring communities.

A baseline survey was conducted to determine the number of water-related sickness cases reported among children in schools in the identified respective schools by the Ministry of Education and Health. The schools that registered a significant high case count among the students, were selected to partner with us in this one year project. The initiative is being implemented in the following 10 schools in the Mumias East Sub-County:

Mahola Primary                 Maraba Primary

Shibinga Primary               Isango Primary

Mwichina Primary             Khaunga Primary

Eshisenye Primary              Epanja Primary

Shianderema Primary         Emakhwale Primary

An End Year survey was conducted in October, 2023 with the major objective of measuring the changes achieved as compared to the baseline survey conducted in January of 2023 before the WASH intervention was initiated among the partner Primary Schools in Mumias East Sub-County. Key area of measurements include: determination of the number of water-related sickness cases reported among children in schools in the identified respective schools by the Ministry of Education and Health. The End Year survey employed cross-sectional methods and in-cooperated both qualitative and quantitative data collection methods, the same tools used for the base line survey that was developed  with extensive desk review and consultations to define key indicators in designing data collection tools. Data was collected at 2 levels that is at Early Childhood Development Education (ECDE) and Primary classes.

 An additional representation of the total number of cases reported at each school over a four-week period is shown in the graph above. The baseline survey revealed that each school encountered high cases for a period of one month, which resulted in a high percentage of absence. The total number of water-related disease cases received in the 10 schools for a period of four weeks was 1806, according to the baseline survey. In all 10 schools, there were a total of 269 cases of menstrual problems among girls in grades 4 through 8. Menstrual hygiene management is an important subject that hasn't been given much attention in schools, but it needs to be. In all 10 schools, there were 500 occurrences of skin/oral infections; the majority of the affected pupils were in lower grades, from PP1 to Grade 3.

Findings of the End Year survey show that reported episodes of waterborne diseases and skin and oral infections within one month has significantly reduced as compared to when the year started during the baseline, including reduced absenteeism for the students weekly. In the end year survey, the results show that 70% overall reduction in diarrheal prevalence and a similar reduction in days of illness among pupils in the partner schools compared to during the base line survey. This reduction in diarrheal prevalence and skin and oral infections was similar for both boys and girls. As per the base line survey conducted earlier in the year, schoolgirls in rural primary schools would prefer to stay at home during their periods rather than face discomfort, inactivity, and embarrassment as a result of inadequate MHM facilities at school. However, the results of the end-of-year survey indicate a noteworthy rise in school attendance among menstruating girls. Equal opportunities for all girls depend on a welcoming and encouraging MHM environment that offers education, absorbent sanitary products, and sufficient WASH facilities.

  2.0:  LESSONS LEARNT

• Improved Health: Positive behavior change in students on WASH can lead to a reduction in the incidence of eater-borne diseases such as diarrhea, cholera, and typhoid, as well as other illnesses caused by poor hygiene practices such as skin and oral infections. This in turn, can lead to improved health and well-being among students.
• Increased attendance: Good WASH practices in schools can reduce absenteeism due to illness caused by poor hygiene practices. When students are healthy, they are more likely to attend the school regularly, leading to improved academic performance and higher graduation rates.
• Positive behavior change in students on WASH is essential for promoting health well-being, and academic success. It is important to implement WASH programs in schools that aim to promote positive behavior change and provide access to safe water, sanitation facilities, and good hygiene practices. Such programs can lead to better health outcomes, improved attendance and academic performance, gender equality, and environmental sustainability.

  3.0: CHALLENGES

• The risk of spreading diarrheal and water borne diseases gets compounded by the lack of regular hand washing and microbial contamination of water in the homes and communities of the students.
• The deeply entrenched belief that menstrual blood is dirty, impure or polluting determines how girls manage menstruation including their choice of menstrual-absorbent hygiene practices, and observance of social, religious, and food restrictions.
• Inadequate WASH facilities in schools can have a significant impact on children’s health and well-being. Without safe drinking water and adequate sanitation facilities, children are at risk of contracting water borne-illnesses such as diarrhoea and cholera. Poor hygiene practices can also increase the risk of infectious diseases, including skin and oral diseases.

 4.0: RECOMMENDATION

• Separate toilets for boys and girls: there needs to be adequate, menstrual hygiene management facilities, private space for changing, adequate water for cloth washing, and disposal facilities for menstrual waste.
• Sufficient group hand washing facilities that allow 10-12 students to wash their hands at the same time. The hand washing station should be simple, scalable, and sustainable, relying on minimum water.
• All water, sanitation and hand washing facilities need to be clean, functional, and well maintained to ensure that the intended results are achieved and monetary investments made in installing these systems are not lost.
• Capacities are to be improved at various levels within the sector, to develop the right mix of skills, knowledge, and experience to help, finance, manage and monitor water, sanitation, and hygiene programmes in schools effectively.
• Water, sanitation, and hygienic behaviour change communication activities should be part of the daily routine of all children. Girls are to be taught menstrual hygiene management by female teachers in a sensitive and supportive manner.
• Safe handling and storage of drinking water should be practiced throughout the school.

 5.0: CONCLUSIONS

Findings of the end year survey suggest that improvements to school water supply and quality, along with sanitation provision and hygiene promotion, can reduce diarrheal illness, skin and oral infections and also increase class attendance among menstruating students. School WASH is especially needed in water-scarce areas to mitigate the diarrheal disease burden on students. Children’s health can greatly benefit from simple water supply improvements such as drilled boreholes and rainwater-harvesting tanks. The findings also suggest that WASH interventions are protective against water-borne diseases only when there was improved WASH conditions in the partner schools. Results from this findings also reveal that the effectiveness of an intervention on reducing water-borne, skin and oral diseases is based on background rates of disease and baseline WASH conditions.